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UNITED STATES OF AMERICA. 



Plate I 




Neevus Lipoirtatod.es . 
( From, a Photograph of one of the author's patients.) 
(Front ispiece .) 



A PRACTICAL TREATISE 



DISEASES OF THE SKIN, 



FOR THE USE OF STUDENTS AND PRACTITIONERS. 



SECOND EDITION, 
THOROUGHLY REVISED AND ENLARGED. 



JAMES NEVINS HYDE, A.M., M.D., 

PROFESSOR OP SKIN AND VENEREAL DISEASES, RUSH MEDICAL COLLEGE, CHICAGO ; DERMATOLOGIST 
TO THE MICHAEL REESE HOSPITAL, CHICAGO ; AND ONE OF THE PHYSICIANS FOR 
i") DISEASES OF THE SKIN TO THE PRESBYTERIAN HOSPITAL, CHICAGO. 



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<\ 




jAPfi 12 1888 "tV 



PHILADELPHIA 

LEA BROTHERS 

1888. 



CO. 






Entered according to the Act of Congress, in the year 1888, by 
LEA BROTHERS & CO., 
in the Office of the Librarian of Congress, at Washington. All rights reserv* 



DORNAN, PRINTER, 
PHILADELPHIA. 



r~ 



MORIZ KAPOSI 



PROFESSOR OP DERMATOLOGY IN THE UNIVERSITY OF VIENNA, AUSTRIA, 



THESE PAGES ARE, WITH HIS GENEROUS CONSENT, 



jftesjjccifullji Inscribed 



THE AUTHOR. 



PREFACE TO THE SECOND EDITION. 



The work of revision, required by exhaustion of the first and 
the demand for a second edition of this treatise, has been carefully 
conducted with results that are declared upon every page here pre- 
sented to the reader. There have been added new chapters devoted 
to the description of several cutaneous maladies whose names were 
a few years ago unknown ; others have been wholly rewritten ; none 
has been left untouched. The need of conforming to the classi- 
fication and nomenclature of diseases of the skin adopted by the 
American Dermatological Association, has involved a labor which 
it is believed has largely added to the practical worth of the book. 
Personal observation of more than ten thousand cases of cutaneous 
diseases in both public and private practice, has furnished an experi- 
ence which has been made to serve here as far as was practicable 
in the illumination of the teaching embodied in almost every para- 
graph. Nearly one hundred pages have thus been added, together 
with a number of new wood cuts and two portraits of rare diseases 
of the skin in colored plates. 

The author is anxious to express his sense of gratitude to the 
profession for the favorable reception accorded to the first edition 
of the treatise; and desires to acknowledge his great obligation in 
the preparation of its successor, to the later authors especially, in 
cutaneous medicine, whose works are named in the brief but selected 
bibliography appended at the close of the volume. 

He has also to extend his thanks to Dr. Frederick W. Mercer, 
and to Dr. Albert J. Ochsner of the Pathological Laboratory of the 
College, for aid in the preparation of specimens and drawings ; as 
also to his assistant, Dr. Frank H. Montgomery, for services ren- 
dered while the work has been passing through the press. 

Chicago, March, 1888. 



PREFACE TO THE FIRST EDITION. 



The increasing recognition of the gravity of many cutaneous dis- 
orders, and of the importance of their accurate study, is shown by 
the rapidly augmenting number of observers in this department of 
medicine, and by the numerous valuable contributions constantly 
made to it, both in this country and abroad. For the convenience of 
the general practitioner it therefore becomes necessary at shortly 
recurring intervals that some one should attempt the task of pre- 
senting in a comprehensive form the results of the latest observation 
and experience. 

The author is aware of the degree to which he must claim indul- 
gence in the present effort to perform this duty. The extent of the 
subject and the limitations of a single volume, require the omis- 
sion of much detail of secondary importance. With regard to that 
which it has seemed proper to include, he has endeavored to write 
concisely, to set forth only what can be held as the truth, to be frank 
in the admission of the weakness with which the most skilful physi- 
cian stands in the presence of many grave and not a few benign dis- 
orders, and to cultivate a wholesome doubt of that which has not 
been shown to be worthy of trust. How far he may have fallen 
short of attaining this end these pages will declare. 

He has to express his indebtedness to the standard w T orks on 
dermatology of foreign authorship, especially the exhaustive and- 
invaluable work of Hebra, and the Lectures on the Diseases of the 
Skin lately given to the profession by Professor Kaposi, which con- 
tain the mature conclusions of his vast experience. With these 
should be named the writings of Sir Erasmus Wilson, Dr. Tilbury 
Fox, Dr. Neumann, Dr. McCall Anderson, Dr. Behrend, and the 
syphilographers, to whose works special reference is made in the 
chapter devoted to their theme. Among the books of American 
authorship, he is under special obligation to the sterling work of Dr. 
Duhring, of Philadelphia, and to the excellent treatises of Drs. 
Piffard, Fox, and Bulkley, of New York. 

All these are named by title in the brief and selected bibliography 



Vlll PREFACE TO THE FIRST EDITION. 

appended at the close of the volume. No less valuable aid has been 
obtained by consulting the papers of American and foreign authors 
contained in the journals specially devoted to diseases of the skin, 
among which, as t he representatives of the English tongue, the 
Archives of Dermatology, lately edited by Dr. Bulkley, and the 
current Journal of Cutaneous and Venereal Diseases, edited by Drs. 
Piffard and Morrow, deserve special mention. 

The author is also very greatly indebted to Dr. Charles Heitzmann, 
<»f New York, not merely for the information gathered from the 
study of his original researches in pathology, but particularly for his 
kindness in furnishing advanced sheets of the chapter on the skin, in 
his work on Microscopic Morphology, which has just issued from 
the press. From this work, with Dr. Heitzmann's permission, 
several illustrations have been borrowed, which appear in the chapter 
on anatomy, the details of which subject are also very largely drawn 
from the same rich store. The first of the drawings representing 
sections of the skin, is from the faithful peucil of Dr. H. D. Schmidt, 
of New Orleaus, who, iu order to produce it, interrupted, without 
hesitation, his arduous labors in connection with the subject of 
pathology. To his colleague, also, Dr. Frederick W. Mercer, of 
Chicago, the author is glad to express his indebtedness for the skill 
with which a number of pathological specimens have been prepared 
and mounted for special study, and original drawings produced for 
the first and several subsequent chapters of the book. To Dr. 
Duhring, of Philadelphia, he is further indebted for valuable sugges- 
tions made during the course of preparation of the manuscript. 

Medicinal measures are, in these pages, expressed in terms of both 
the apothecaries' scale and the metric system. It is to be noted, how- 
ever, that the latter are not in all cases literal translations of the terms 
of the former, many of the formulae, especially those for preparations 
designed to be topically employed, being metrically composed, the 
relative proportions of the ingredients remaining unchanged. 

The changes which it has been advisable to make, in the matter of 
nomenclature, classification, and other equally important subjects, are 
concisely explained in the chapters devoted to each. 

Chicago, No. 240 Wabash Avenue, 
February, 1883. 



CONTENTS. 



Anatomy and physiology of the skin 17 

General symptomatology 48 

General etiology 60 

General diagnosis ........... 66 

General prognosis . . . . . . . . . . .71 

General therapeutics . . . .73 

Classification 90 



DISEASES OF THE SKIN. 

CLASS I. 
DISOEDERS OF THE GLANDS. 

1. Of the Sweat Glands 95 

Hyperidrosis .95 

Sudamen 99 

Miliary fever 100 

Anidrosis • 101 

Bromidrosis 102 

Chromidrosis ........... 103 

Uridrosis 105 

Dysidrosis 105 

Hsematidrosis 106 

2. Of the Sebaceous Glands 107 

Seborrhcea 107 

Comedo 118 

Cyst ■ 124 

(A.) Milium 124 

(B.) Steatoma 126 

Asteatosis 128 

CLASS II. 

INFLAMMATION'S. 

Exanthemata 129 

Morbilli (measles) 130 

Rotheln (German measles) 133 

Scarlatina (scarlet fever) ........ 134 



X CONTENTS. 

PAGE 

Variola (smallpox) 139 

Varioloid 142 

Varicella (chicken-pox) 146 

Vaccinia (cow-pox) 149 

Erythema simplex 153 

Erythema intertrigo 156 

Erythema multiforme ......... 159 

Urticaria 163 

Urticaria pigmentosa ......... 164 

Dermatitis 171 

(A.) Traumatica 172 

(B. ) Venenata . 172 

(C.) Calorica 175 

Congelatio 177 

(D.) Medicamentosa 178 

(E.) Gangrenosa 187 

Erysipelas 188 

Furunculus 195 

Anthrax 198 

Pustules from cadaveric infection ....... 201 

Pustules and other lesions resulting from wounds inflicted by rep- 
tiles and insects .......... 202 

Delhi boil, Aleppo evil, Biskra bouton 202 

Phlegmona diffusa 204 

Pustula maligna 205 

Herpes . 208 

Herpes iris 211 

Herpes gestationis 212 

Herpes zoster 212 

Dermatitis herpetiformis 218 

Psoriasis 221 

Pityriasis maculata et circinata ........ 239 

Dermatitis exfoliativa 240 

Dermatitis exfoliativa infantum 242 

Pityriasis rubra ........... 243 

Lichen planus ............ 246 

Lichen ruber ............ 250 

Eczema 253 

The local varieties of eczema 291 

Eczema of the scalp 2!il 

Eczema of the face 2i»4 

Eczema of the lips 2!H5 

Eczema of the nostrils 297 

Eczema of the ears 298 

Eczema of the lids 299 

Eczema of the beard 300 

Eczema of the genital organs 302 

Eczema of the anus and anal region ..... 305 



CONTENTS. XI 

PAGE 

Eczema of the nipple and breast of women .... 307 

Eczema of the umbilicus 308 

Eczema of the superior and inferior extremities . . . 308 

Eczema of the hands and feet 310 

Eczema as it affects the nails ....... 313 

Eczema of the tropics (prickly heat) 314 

Prurigo 316 

Acne 319 

Acne Rosacea 329 

Sycosis 334 

Dermatitis papillaris capillitii ........ 338 

Impetigo 340 

Impetigo contagiosa 342 

Impetigo herpetiformis 344 

Ecthyma 345 

Pemphigus 348 

CLASS III. 

HEMORRHAGES. 

Cutaneous haemorrhages .......... 353 

Purpura ............. 354 

(A.) Simplex 354 

Purpura urticans ......... 355 

Purpura rheumatica (peliosis rheumatica) .... 355 

(B.) Heemorrhagica (morbus maculosus Werlhofii) .... 356 

Purpura scorbutica (scurvy) . . . . . . 357 

Purpura pulicosa 357 

Haemophilia ......... 357 

CLASS IV. 
HYPERTROPHIES. 

1. Of Pigment 360 

Lentigo 360 

Chloasma . 361 

Melanoderma, chloasma cachecticorum ..... 362 

Addison's disease 362 

Argyria '..... 363 

2. Of Epidermal and Papillary Layers 366 

Keratosis 366 

(A.) Pilaris 366 

(B.) Senilis 368 

Molluscum epitheliale 369 

Callositas 374 

Callositas of hands with unusual complication .... 375 

Perforating ulcer of the foot (mal perforant du pied) . . 375 

Clavus 378 



Xll CONTENTS. 

PAKE 

Cornu cutaneum 379 

Verruca 381 

Multiple cutaneous tumor, accompanied by intense pruritus . 385 

Papilloma 385 

Verruca necrogenica ......... 386 

Nanus pigmentosus .......... 387 

Xerosis 388 

Ichthyosis 390 

Simplex . . 390 

Hystrix 390 

Ichthyosis congenita 392 

Onychauxis 385 

Hypertrichosis 398 

3. Of Connective Tissue 404 

Sclerema neonatorum ......... 404 

Scleroderma ........... 405 

Morphcea 409 

Elephantiasis ........... 412 

Lymph scrotum . . . . . . . . . .417 

Rosacea 417 

(A.) Erythematosa 417 

(B.) Hypertrophica 418 

Framboesia ... 419 

Parangi ............ 421 

Donda ndugu 421 



CLASS V. 

ATROPHIES. 

1. Of Pigment 422 

Leucoderma ........... 422 

Albinismus 423 

Vitiligo 424 

Canities 427 

2. Of Hair 429 

Alopecia 429 

( iongenital 429 

Senile 430 

Premature 430 

Alopecia furfuracea .......... 433 

Alopecia areata 435 

Neurotica ........... 440 

Atrophia pilorum propria 440 

Trichorexis nodosa 441 

Nodose swellings of shaft of hair 422 

Piedra 443 

3. Of Naii 443 

Atrophia unguis .......... 443 



CONTENTS. Xlll 

PAGE 

4. Of Cutis 444 

Atrophia cutis 444 

Atrophia senilis .......... 444 

Atrophia maculosa et striata ........ 445 

Blanching atrophy of the skin 446 

Glossy fingers 446 

CLASS VI. 

NEW GrEOWTHS. 

1. Of Connective Tissue 447 

Keloid 447 

Cicatrix . . . 449 

Fibroma 452 

Neuroma 456 

Xanthoma ............ 458 

Adenoma 461 

2. Of Muscular, Tissue . . .462 

Myoma 462 

3. Of Vessels . .464 

Angioma 464 

Naevus vasculosus 464 

Telangiectasis 465 

Angioma pigmentosum et atrophicum ...... 466 

Angioma cavernosum ......... 467 

Lymphangioma . . . . . . . ... . . 470 

4. 

Rhinoscleroma 471 

Lupus erythematosus 473 

Lupus vulgaris ........... 479 

Scrofuloderma . . . . . . . ... . . 489 

The papular scrofuloderm (lichen scrofulosorum) . . . 491 

The small pustular scrofuloderm 492 

The large pustular scrofuloderm 493 

Tuberculosis of the skin . 494 

Ainhum 495 

Podelcoma 495 

Synovial lesions of the skin 496 

The Sartian disease . . . . . . . . . 597 

Syphiloderma 497 

Chancre 498 

Syphiloderma maculosum 504 

Papulosum 507 

Vesiculosum 513 

Pustulosum 514 

Bullosum 517 

Tuberculosum 517 

Tuberculosum serpiginosum 517 

Gummatosum •. . . . . 519 



Xiv CONTENTS. 

PAGE 

Erythanthema syphiliticum ....... 521 

Syphiloderma infantile, acquisituin et hsereditarium . . . 521 

Chancroid 544 

Lepra 549 

(A.) Lepra tuberosa 549 

(B.) Lepra maculosa 552 

(C.) Lepra ansesthetica 553 

Pellagra 560 

Actinomycosis 561 

Carcinoma ............ 561 

Epithelioma ........... 562 

Superficial ........... 562 

Deep, or tubercular ......... 563 

Papillary 563 

Cancer of the head ......... 564 

Cancer of the lower lip 565 

Cancer of the genital organs 565 

Cancer of the extremities 566 

Paget's disease of the nipple 566 

Cancer of the connective tissue ....... 573 

Tuberose carcinoma ......... 573 

Melanotic, or pigmented carcinoma ...... 574 

Sarcoma ............. 575 

Melanotic sarcoma (melano-sarcoma) 577 

Mycosis fungoides 578 

CLASS VII. 

NEUBOSES. 

Hyperesthesia 581 

(A.) Pruritus 581 

Pruritus narium ......... 583 

Pruritus genitalium 583 

Pruritus ani 583 

Pruritus hiemalis (prurigo hyemalis, etc.) .... 588 

Prairie itch, etc 589 

(B.) Dermatalgia 590 

Anaesthesia 591 

Vasomotor and trophic neuroses 592 

Myxoedema 595 

CLASS VIII. 

PARASITIC AFFECTIONS. 

1. Vegetable 597 

Tinea favosa 597 

Tinea trichophytina 603 



CONTENTS. XV 

PAGE 

(A.) Tinea circinata 604 

Onychomycosis 606 

Tinea imbricata (Tokelau ringworm, etc.) . . 611 

(B.) Tinea tonsurans 611 

Tinea kerion 617 

(C.) Tinea sycosis 618 

Precautions to be observed in managing tinea favosa 

and tinea trichophytina ...... 624 

Tinea versicolor ......... 625 

Myringomycosis . 629 

Erythrasma 629 

La Perleche 631 

2. Animal 631 

Scabies 631 

Demodex folliculorum 642 

Pulex penetrans (sand flea) 643 

Filaria medinensis (guinea worm) 643 

Cysticercus cellulosse 644 

Echinococcus . . » . . . . . . . . 645 

Distoma hepaticum 645 

Leptus (harvest bug) 645 

Kriptoptes monunguiculosis 646 

Dipterous larvae in the human skin 647 

Ixodes (wood-tick) 648 

Pediculosis 649 

Pediculosis capillitii ......... 649 

Pediculosis corporis 652 

Pediculosis pubis ......... 655 

Pediculi and acari transferred to man from the lower 

animals .......... 657 

Cimex lectularius ........ 657 

Pulex iritans (flea) . ... . . . . .659 

Culex pipiens (mosquito) . 659 



LIST OF ILLUSTRATIONS. 



Plate I. 



Case of naevus lipomatodes, from a colored photograj)h of one of the author's 
patients {frontispiece). 

Plate II. 

Xanthoma of elbows and knees, from a photograph of one of the author's 
patients (page 458). 

FIG. PAGE 

1. Vertical section of the skin of the thumb ...... 18 

2. Subcutaneous fat-tissue, after extraction of fat by turpentine . . 20 

3. Columnae adiposse 21 

4. Vertical section of the skin, after injection from beneath with 

Berlin blue 22 

5. Vascular and nervous papillae 23 

6. Horizontal section of the scalp of a negro ..... 24 

7. Prickle-cells of the mucous layer ....... 25 

8. (a) Pacinian body after staining with silver, showing superim- 

posed endothelial layers; (b) Section of the same from a duck's 

bill 30 

9. Section of hair-follicle during the formation of a new hair . . 34 

10. Hair-follicle in longitudinal section 34 

11. Lower portion of hair-pouch from the lip of a kitten ... 36 

12. Transverse section of hair and follicle 37 

13. Sebaceous glands of the second class from the alae of the nose . . 40 

14. Coil-gland . . . ' . .41 

15. Sweat-pore, traversing the epithelial layers of the skin ... 42 

16. Vertical section of one-half of nail and matrix . . . . *46 

17. Implantation of the nail at its border . . . . . .47 

18. Irido-platinum needle . . . - . . . . . .89 

19. Milium needle 89 

20. Scarifying spud 89 

21. Epilating forceps 89 

22. Grappling forceps 89 

23. Skin-grafting scissors 89 

24. Cutisector 89 

25. Dermal curettes 90 

26. Glass pleximeter 90 

27. Comedo-extractor 90 



XV111 LIST OF ILLUSTRATIONS. 

I l«;. PAGE 

28. Cutaneous punch 90 

29. Section of a comedo 120 

30. Cysts of the scalp, one of them laid open to exhibit the contents . 127 

31. Microphotograph of the bacillus scarlatiuae 138 

32. Vertical section of pustule at the beginning of pustulation in variola 144 

33. Vertical section of one-half of an undeveloped pustule . . . 145 

34. Vertical section of anthrax ........ 200 

35. Section of anthrax 200 

36. Bacilli of malignant pustule 207 

37. Longitudinal section of the third spinal ganglion of the right lumbar 

region, from a case of zoster 216 

3-v Vertical section of skin in psoriasis 226 

39. Vertical section of the skin of the forearm, from a case of chronic 

eczema 265 

40. Molluscum epitheliale 370 

41. Molluscous corpuscles 371 

42. The author's case of molluscum verrucosum 373 

' [ Varieties of cutaneous horns 380 

44. J 

45. Vertical section of a pointed wart 383 

46. Verruca necrogenica 386 

47. Ichthyosis hystrix, vertical section 393 

48. The Russian " dog-faced man " 399 

49. Elephantiasis of foot and leg 412 

50. Elephantiasis of the scrotum ........ 413 

51. Vitiligo in a negro boy 425 

52. Trichorexis nodosa 441 

53. Keloid 448 

54. Multiple fibromata 452 

55. Large single fibroma 452 

56. Neuroma of the skin 457 

57. Microscopic structure of neuroma of skin 457 

58. Lupus erythematosus of the face, from a photograph of one of the 

author's patients . . . 474 

59. Lupus vulgaris of the face, from a photograph of one of the 

author's patients 480 

60.. Section of a lupus nodule 482 

61. Section of lupus of the face ....*... 483 

62. Facial cicatrices of tubercular syphilodermata, from a photograph 

of one of the author's patients ....... 503 

63. Syphiloderma papillosum 508 

64. Vegetating condylomata of the vulva 511 

65. Palmar syphiloderm 512 

66. Ulcerative tubercular syphiloderm 518 

67. Syphilitic gummata of head and face 520 

68. Lee's lamp for fumigation 538 

69. Lepra tuberculosa 550 






LIST OF ILLUSTRATIONS. XIX 

FIG. PAGE 

70. Tubercular leprosy, from a photograph of a leper in the Sandwich 

Islands 551 

71. Anaesthetic leprosy, with mutilating results, from a photograph of 

a leper in the Sandwich Islands ....... 553 

72. Larynx of a leper, with lepra tuberculosa 554 

73. ) 

74 y Larynges of lepers, with tubercular leprosy 555 

75. Bacilli of leprosy, from one of the author's patients . . . 556 

76. Epithelioma, vertical section 567 

77. Sarcoma, microscopical appearances in section of nodule removed 

from one of the author's patients ....... 576 

78. Mycosis fungoides, drawn from an oil painting of one of the author's 

patients 578 

79. Achorion Schoenleinii 600 

80. Epidermis invaded by the trichophyton ...... 607 

81. Hair invaded by the trichophyton 614 

82. Filaments and spores of the trichophyton from the beard . . 621 

83. Microsporon furfur 627 

84. Microsporon minutissimum ........ 630 

85. Female acarus, fecundated 634 

86. Acarian furrow 635 

87. Demodex folliculorum 642 

88. Leptus . 646 

89. Leptus autumnalis 646 

90. Acarus hordei 646 

91. (Estrus (larva?) 647 

92. Larva? removed from body of child ....... 647 

93. Pediculus capillitii (male) 649 

94. Ova of head-louse, attached to hair 650 

95. Pediculus corporis (female) 652 

96. Pediculus pubis 656 



I. 

AN ATOMY AND PHYSIOLOGY OF THE SKIN. 



The skin of the human body is its living envelope, intimately 
associated with underlying structures, and by its situation brought 
into intimate relation also with the external world. It is a complex, 
elastic, and sensitive organ, varying greatly in different conditions of 
climate, age, sex, health, and race ; and differing also in the charac- 
teristics exhibited in different localities upon the same individual. 
Thus, in color there is a wide range between the fair skin of the 
blonde and the black of the negro, betweeen the rosy pink of the 
infant's palm and the dark brown hue of the genital region of the 
aged. The skin varies also in pliability and thickness, being delicate 
and lax over the lids, the lips, and the prepuce ; and much thicker 
and more firmly attached over the palms and the soles. 

It is important to note that the appearance of the skin, even in 
conditions of health, also changes within appreciable limits. It is the 
exposed parts, such as the face, which the eye of the physician. most 
frequently searches, and which betray evidence of mental emotions, 
physiological fluxes, sedentary or active habits of life, and fatigue or 
unusual conditions of vigor. 

Viewed externally, the skin is seen to be traversed by superficial 
and deeper furrows, dotted by numerous depressions representing the 
mouths of its follicles, and provided very generally with coarse or 
fine downy hairs which are in some parts represented by a growth 
sufficient to conceal the skin from view. This pilary growth serves 
not merely as an ornament of the body, but also as a protection to 
some of- its regions most sensitive to thermal changes. 

By its extraordinary sensitiveness to different degrees of temperature 
and to the physical properties of the bodies with which it is brought 
into contact, the skin becomes, even when unaided by the eye, a 
valuable means of preserving the human frame from external injury. 
This protective function is, in part, related to the horny character of 
its outer layer, as a consequenceof which the loss of essential fluids 
and the ingress of noxious substances are equally restricted. 

One of the most important functions of the skin is the part which 
it plays in the regulation of the bodily temperature. The temperature 
variations at its surface, modified naturally by the character and 
quantity of the clothing, when such is worn, produce corresponding 
variations in the smooth muscles and contractile bloodvessels of the 
skin. By enlargement or diminution of the lumen of these vessels, 
whether resulting directly from the action of heat or cold at the 



is 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



surface, or indirectly through an effect upon the vasomotor centres, 
large quantities of Mood are brought to or removed from the super- 
ficies of the body. In the one case, the blood is cooled by evaporation 



Fig. 1. 







38 



d 




. 












Vertical section of the skin of the thumb, partly diagrammatic. «, stratum corneum, traversed by 
ducts of two glands ; b, rete mucosum with prolongations extending between papillae beneath ; between 
a and b is seen the stratum lucidum ; c, papillary layer of coriuin. Near the centre of the figure is 
seen a nervous papilla ; d, reticular layer of cor in m with vascular plexus, nucleated connective tissue 
and interspaces ; e, four coil-glands ; /, fat-globules in the meshes of the connective tissue. 

at the surface; in the other, the loss of heat by such evaporation is 
greatly restricted. This process is materially influenced by accelera- 
tion or retardation of the heart's action, whether produced by moral 



SUBCUTANEOUS TISSUE. 19 

or physical causes. It is also modified by the occurrence of sweating, 
as a result of which heat iu varying amounts is rendered latent ; and 
either watery vapor escapes from the surface or sweat is exuded in 
drops, the aggregate of which may be several pounds in weight in 
the course of twenty-four hours. 

In a limited degree, the skin is capable of acting as a respiratory 
agent, eliminating carbonic acid gas with watery vapor, and possibly 
also absorbing oxygen in small amount. Its power of absorbing 
aliments, medicaments, and toxic substances, in either gaseous or 
liquid state, is greatly restricted so long as its horny external 
covering is intact. Such absorption, when it occurs, is probably 
effected through the portal of the ducts of the cutaneous glands. 
Gaseous and volatile substances, as well as several of the oils and 
fats, may at times penetrate the skin through these avenues. 

The skin is provided with a natural unguent, by which, in a state 
of health, it is constantly anointed. The fatty and oily secretions of 
the skin are concerned, not merely in the anointing of the general 
surface and of the hairs, but also in the regulation of the bodily 
temperature, by preventing the maceration of the tissues by the 
sweat. 

The complex organ which is called the skin is essential to the life 
of the individual. The sexual, and possibly other organs of the 
human body, may have their functions arrested, or be even obliterated 
by destructive processes, and life still continue ; but if the functions 
of the skin were all suspended for a sufficient period of time, the 
result would be fatal. In its important relations alone to the compli- 
cated processes by which the heat of the body is maintained at a 
relatively fixed standard, the skin exhibits its importance to the 
general economy. It is thus seen to be, not an isolated membrane 
stretched mechanically over an artificial machine, but one of several 
living and potential systems of the body, each of which is in inti- 
mate union with all others. 

The integument of the body, when studied by the aid of the 
microscope, is found to be composed of several organic parts. These 
are : the subcutaneous connective tissue resting on the deeper struc- 
tures of the body; then, more externally, the corium, or true skin; 
lastly, an outermost coat, the epidermis, or cuticle. Beside these, the 
skin contains coil-glands, sebaceous glands, hairs, nails, blood- and 
lymph- vessels, muscles, pigment, and nerves. It will be instructive 
to study the deeper parts before those more superficially disposed, as 
their mutual relations are thus made clearer. 

Subcutaneous Tissue. 

The subcutaneous tissue is differentiated from the corium between 
the third and fourth months of foetal life. It is a structure serving 
a mechanical purpose as a receptacle for fat, and for the support of 
vessels and nerves passing from the tissues beneath to the corium, 
which lies next above it. It contains, also, coil-glands, some of the 



20 



ANATOMY AND PHYSIOLOGY OF TIIE SKIN 



hair- follicles more deeply seated than their fellows, and Pacinian 
corpuscles. There is no distinct boundary line between its upper 
limits and the overlying corium, to which it projects columnar masses 
of fat, extending obliquely to the coil-glands and the hair-follicles 
above, often with lateral, horizontally disposed prolongations of 
similar shape. It is built up of loose connective-tissue bundles, pro- 
longed from the aponeuroses, fascia?, and the membranes lying 
beneath. 

It is firmly attached to the skin over the extensor surfaces of the 
articulations, the palms, the soles, and the groins by short and coarse 
bundles, between which are single or multilocular spaces lined with 
endothelia, secreting a mucoid fluid. These are the bursa? mucosa?. 
Elsewhere, as in the eyelids, the penis, the scrotum, and the auricle 
of the ear, the attachment to the skin is by loose, delicate connective 
tissue, containing no fat-globules. All other fibrous tracts are 
arranged obliquely, admit, by their extension, of various degrees of 
pliability, and inclose rhomboidal spaces containing more or less 
numerous fat-globules. These are lobulated, bounded by a delicate, 
fibrous connective tissue, and abundantly supplied with bloodvessels. 
This is termed the panniculus adiposus. 



Fig. 2. 



Subcutaneous fat tissue, the fat ha 
tive tissue, carrying injected bluodvi 
51111 diameters. (After IIkitzmann.) 




bundles of fibrous connec- 
b oblong nuclei. Magnified 



The deposit of fat in the body is greatly reduced in all diseases 
productive of emaciation, but never wholly disappears in life. In 
cases of obesity, fat is deposited in excess of normal limits, and may 
then be concerned in the production or aggravation of disease. It is 



THE CORIUM. 
Fig. 3. 



21 




Columnse adipose, a, epidermis ; b, erector pill muscle ; p horizontal prolongations of the column ; 
c, coil-gland suspended in the latter ; /, fibrous bundles of corium ; g, panniculus adiposus ; 7c, band of 
fibrous tissue extending to the latter. (After Warren.) 

largely due to the greater or less volume of the panniculus adiposus, 
that the natural outlines of the body are made graceful and attractive 
to the eye, or the reverse. 

The Corium. 

The Corium, Derma, Cutis Vera, or True Skin, is composed 
of bundles of fibres of connective tissue, whose decussations produce 
a dense felt-work, coarsest toward the subcutaneous tissue, upon which 
it rests inferiorly, and finest superiorly in the outermost portion, 
which is in contact with the epidermis above. Its general character- 
istics are well described by Heitzmann as follows : " The bundles are 
bounded in many instances by a very dense basis-substance, repre- 
senting the elastic fibres, and separated from each other by narrow 
layers of a cement-substance (Thomsa), which, in its chemical features, 
is kindred to the glue-giving basis-substance of the fibrous connective 
tissue in general. In this cement-substance there are imbedded deli- 
cate formations of protoplasm, greatly varying in amount in the 
derma of persons of different age. They represent formations analo- 
gous to nuclei, formerly called l connective-tissue cells/ at present 
considered as compact masses, or delicate reticular layers of living 
matter, which, with a power of five hundred diameters of the micro- 
scope, look finely granular. The whole glue-giving basis-substance 
of the bundles is traversed by a delicate reticulum of living matter, 
in direct union with all protoplasmic formations between the bundles, 
with all blood- and lymph-vessels, with all nerves, and with the 



22 ANATOMY AND PHYSIOLOGY OF THE SKIX. 

columnar epithelia, nearest to the capillary layer. Only the meshes 
of the network of the living matter contain the glue-giving basis- 
substance, which, as the history of development of the connective 
tissue demonstrates, is produced by a chemical alteration of the life- 

PiO. 4. 




Vortical section of skin afiei injection, from beneath, of areolar tissue with Berlin blue. 
a, epidermis; /, curium; y, panuicuius adiposus. (After Warren.) 

less' protoplasmic fluid itself. The bundles of the connective tissue 
of the derma accompany all elongations of an epithelial character. 
They produce the follicles around the root-sheaths of the hair, the 
capsules around the coil-glands, and the layers which surround their 
duets. The bundles of connective tissue are traversed in an oblique 
direction by bundles of smooth muscular fibres, by relatively scanty 
bloodvessels in the derma, by numerous capillaries in the papillary 
layer, by a system of lymphatics, and by numerous medullated and 
non-medullated nerves." 

Pars Reticularis. — The reticular layer of the corium is made 
up, as has been seen, of interlacing connective-tissue bundles, with 
interspaces increasingly larger from without inward. The fineness of 
the bundles increases, on the contrary, from within outward, being 
finest where the minute papilhe of the corium project into the rete, 
and coarsest near the subcutaneous tissue. 

Pars Papillaris. — The papillary layer of the corium lies in 
contact with the rete above, and is connected below with the deeper 
reticular portion of the true skin. Between the rete and the papilla? 
of the derma a hyaline substance is interposed which Unna believes 
may be identical with the so-called cement-substance described as 
separating the fibrillar of the corium. The basal membrane once 



THE CORIUM, 



23 



thought to be stretched between the rete ruucosum of the epidermis 
and the papillary layer of the corium, cannot be demonstrated to 
exist. 

Fig. 5. 




Yascular and nervous papillce. a, vessel ; b, nervous papilla ; c, vessel ; d, nerve-libre ; e, cor- 
pusculum tactus; /, transversely divided nervous filaments ; g, epithelia of rete. (After Biksiadecki.) 

The name of this portion of the derma is intended to describe its 
chief characteristic, the existence of numerous digital prolongations 
of the corium, made up of delicate fibres of connective tissue, which 
do not interlace, and are abundantly provided with nuclei. The 
papillae spring each from a single, or several from a common, ovoid 
base ; their bulbous, conical, or blunt apices reaching into the rete, 
which also dips down between them. They differ in size in different 
parts of the body, and also in their disposition and shape, being in 
places arranged in linear series, and in others in concentric whorls, 
with definite centres, producing thus crossing furrows, visible to the 
naked eye as markings upon the outer surface of the epidermis. 

In horizontal sections of the skin, the papillae, being transversely 
divided, appear as circular or ovoid areas, in which can be recognized 
centrally a transversely or obliquely divided capillary loop. Between 
these areas the inter-papillary reticulum of the mucous layer is seen. 

According to Unna, who bases his statements upon the wide varia- 
tion between the largest sized papillae and their entire absence in some 
regions, the papillary layer of the corium represents merely " an ex- 
tremely variable border-phenomenon." Certain it is that the growth 
of the rete downward and of the corium upward results in mutual 
effects of pressure and counter -pressure whose equilibrium is con- 
stantly adjusted by the mechanical and vital necessities of such union. 



24 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

When the papillae are completely exposed, after the removal of the 
overlying so-called cement-substance and of the epidermis above, 
their exterior surface is seen to be uniformly marked with series after 
scries of alternating furrows and ridges of exceeding delicacy, more 
or less concentrically disposed. These are supposed by Unna to be 
grooves with ridges on either side, into which are admitted corre- 
sponding dentations to be recognized on the under surface of the layer 
of epithelial cells next to the corium. 



Fig. 6. 



Wmm D 

Scalp of a colored man — horizontal section. B, rete mucosum ; Pi, row of columnar epifhelia, cut 
obliquely, supplied with dark-brown pigment-granules; Pa, papilla, cut transversely; D, derma. 
Magnified 500 diameters. (After Heitzmann.) 

Two varieties of papilla? are distinguished — the vascular and the 
nervous ; the former containing the terminal loops of a minute artery 
and vein ; and the latter, the ultimate filamentous termination of a 
non-medullated nerve-fibre. 

The greater number of papilla? are of the vascular variety, being 
traversed by a vertically disposed loop of vessels, consisting of an 
arterial and venous capillary. Their office is evidently not merely 
to supply nutriment for the epidermis above, but also to provide for 
the cooling of the blood when brought in large quantities to the sur- 
face of the body. Occasionally, two or more of such loops can be 
recognized in a single papilla. 

The nervous papillae contain the tactile corpuscles, which subserve 
an important purpose in providing for the insensibility of the integu- 
ment. These are described in connection with the nerves of the 
skin. It is to be noted that ultimate terminations of nerves can be 
recognized in the vascular papillae, and that at times minute vascular 
loops can be seen in the papilla? largely occupied with the corpuscles 
of touch. 

The Epidermis. 

The Epidermis, Scarf-skin, or Cuticle, is the most external 
of the several membranes of the body, being in close contact on one 
side with the corium, or true skin, and exposed on the other to the 



THE EPIDERMIS. 25 

atmosphere by which it is surrounded. The latter surface is there- 
fore relatively drier, while the former is constantly moistened by 
fluids from the vessels which ramify beneath it. 

No genetic relation can be established between the epidermis and 
the corium, intimate as is their union and mutual relationship. The 
former is developed from the ectoderm, the latter from a superficial 
layer of the mesoblast. Their behavior both in health and disease 
is marked by the widest difference. 

The epidermis differs greatly in thickness in different portions of 
the body, that, for example, of the palms and soles exceeding, in 
vertical section, that which covers the dorsum of these same organs, 
and that protecting such sensitive parts as the lids, lips, temples, and 
prepuce. 

The epidermis is composed of the following layers, named in order 
from within outward : the stratum mucosum, the stratum granulosum, 
the stratum lucidum, and the stratum corneum. All of these several 
strata, or layers, are histogenetically derived from the one which is 
deepest in situation. 

The Stratum Mucosum, Mucous Layer, Prickle-layer, 
Eete Mucosum, Rete Malpighii or Malpighianum, is the 
deepest of the epidermal layers, and rests upon the corium below. The 
latter is intimately united with it by a series of interdigitations which 
are commonly described as prolongations of the derma into the sub- 
stance of the rete, but it is equally true that the rete sends down 
prolongations into the derma. The two, for reasons which doubtless 
originate in the need of an intimate union to resist friction and to 
insure vascular supply, are thus closely locked together. 

The stratum mucosum is built up of nucleated epithelia, epithelial 
cells, or corpuscles, polyhedral in outline and diffusely colored. 
These are masses of granular protoplasm., 
living matter, which by their relations to Fig. 7. 

each other form a protoplasmic network en- 
veloping the entire surface of the body and 
lining all channels and cavities which are in 
direct or indirect connection with the surface. 
These elements are flattened by reason of their 
apposition, and separated from each other by 
an intercellular substance, which has been de- 
scribed as a " cement-substance." There is, 
without question, a system of channels be- 
tween the epithelia, by which the fluids of 
nutrition are conveyed from cell to cell. All 
are, however, uninterruptedly united to each 
other by means of delicate spokes, known as Priokle ' cel,s la ^ r _ the mucous 
prickles, spines, or thorns. The living mat- 
ter, which produces a delicate reticulum within each protoplasmic 
body, its points of intersection being termed nuclei, nucleoli, and 
granules, furnishes the filaments already described, which thus pro- 




26* ANATOMY AND PHYSIOLOGY OF THE SKIN. 

duce continuity through all the living layers of the epithelial elements, 
as well as through the underlying layers of the connective tissue. 
The epithelia are unprovided with either blood- or lymph-vessels ; 
hut. when living, are supplied with a large number of nerves, which, 
in the shape of very minute beaded fibres, traverse the intercellular 
substance, and are in direct communication with the reticulum of 
living matter within the protoplasmic bodies themselves. 

The living masses of protoplasm, just described, play the most 
important part in all the pathological and physiological proa 
observed in the skin. It is probable that, in the embryo, all the 
appendages of the skin are firmed directly by their assimilative and 
reproductive processes ; and it is certain that, in health and disease, 
they furnish the organic matter of all secretions. 

The epithelia next the corium are columnar in form, of a diffuse 
brownish hue, and arranged with their long axes nearly at right 
angles to the plane of that portion of the corium upon which they 
are superimposed. More externally they have pronounced poly- 
hedral outlines, and the cell nucleus of each is large and distinct. 

Above this columnar-shaped pavement, irregularly rounded and 
cubical epithelia, with large, single or multiple, spherical nuclei, are 
packed between the papillae of the corium, rising from below; and 
horizontally flattened bodies of the same general appearance lie in 
strata above the level of the conical apices of the papillae. Here the 
threads of protoplasm between the cells are voluminous, forming 
thick and broad strands connecting the elements. Between these, 
outwandered leucocytes may at times be recognized. In the more 
externally disposed rows of epithelia the prickles become shorter and 
the cells flatter, till finally they lie in a uniformly horizontal plane. 

The Stratum Granulosum, or Granular Layer of the epi- 
dermis, is built up of one or two, rarely more, rows of horizontally 
disposed granular bodies, united to each other by short and broad 
threads. Between these, the intercellular spaces are so contracted 
that nutritive fluids cannot filter easily outward ; and the nuclei of 
the cells are usually shrunken in size. These have been carefully 
studied by Ranvier, Kolliker, Waldeyer, and others. According to 
these observers, the roundish granules which give this layer of epi- 
thelium its peculiar name and appearance, consist of eleidin, or 
kerato-hvalin, a substance essential to the process of cornification in 
the elements miking up the horny layer of the skin, nails, etc. 
These granules begin to appear in the neighborhood of the nuclei of 
some of the large prickle-cells in the rete, but are best studied in the 
granular layer, whose cells are often completely filled with them. 
According to Unna, the color of the skin in the white races depends 
upon this layer alone. 

The Stratum Luoidum, or Septum Lucidum, of Oehl, lies im- 
mediately above the stratum granulosum, and appears under the 
microscope as a delicate, brightly colored line, consisting of two or 



BLOODVESSELS. 27 

three rows of transversely disposed, glistening epithelia, differing in 
translucency from those situated on" either side. It thus marks with 
tolerable distinctness the boundary lines of the rows of cells above 
and below it. Its epithelial bodies have suddenly lost the refractive, 
shining granules of kerato-hyalin, conspicuous in the stratum granu- 
losum below. These granules are generally supposed to have disap- 
peared in consequence of their solution in the protoplasm of the cell- 
body, which has thus acquired an added brilliancy and clearness. 

The Stratum Corneum, or Horny Layer of the epidermis, is 
its outermost aud widest layer, extending from the stratum lucidum 
below to the external environments of the body. In its lower por- 
tion, the polygonal plates of which it is composed indicate very 
clearly their relationship to the cells in the prickle-layer. The nuclei 
appear in places, only, as shrivelled and inconspicuous relics of the 
protoplasmic threads. Occasionally, on the edges, rudiments of the 
prickle-threads may still be recognized. Still more externally, the 
dried, lifeless, and horn-like plates of which this layer is composed, 
become mere cornified shells, generally lying in horizontal strata, 
more curled and wrinkled as the surface of the skin is reached, often 
imbricated, but preserving the polygonal outlines of epithelia relieved 
of the forces of pressure and counter-pressure exerted in the deeper 
parts of the epidermis. These elements are rarely pigmented, save 
in the case of the negro, where the intense staining of the deepest 
parts of the mucous layer is to a degree spread to the external strata. 
Such staining in the colored races is produced by granules of pigment 
arranged about an unaffected nucleus in the prickle-cells. 

According to Unna, after digestion with pepsin and trypsin, it is 
seen that the horny cells are connected by more or less persistent 
threads, visible after more prolonged digestion as a large-meshed 
reticulum, with strands formed from a double row of cornified fila- 
ments united by short horny bridges. 

Bloodvessels. 

The Arteries and Veins supplying the skin spring from sub- 
cutaneous branches which penetrate the fascia? beneath, and proceed 
by subdivision to be distributed to all portions of the integument 
below the epidermis, the distribution being especially abundant about 
the glands and follicles of the skin, and the inferior and superior 
parts of the corium. They are always more abundant upon the flexor 
than the extensor faces of the extremities. Just beneath the papil- 
lary layer of the corium there is a minutely ramifying plexus of fine 
capillaries, whose loops extend into the papillae above, as already de- 
scribed. This and the coarser plexus in the deeper portion of the 
derma are so well defined that they might well be designated as supe- 
rior and inferior partes vasculares of the corium. Still a third vas- 
cular district is found in the subcutaneous connective tissue where 
the vessels are numerous. 



28 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

The arterioles which supply the sweat-glands surround the coils 
of the latter in a delicate basket-like plexus, and terminate in two 
or three veinlets, one of which always accompanies the duct of the 
gland upward as far as the papillary layer, where it anastomoses with 
the vessels of that part of the skin. The ascending arterioles supply 
also the .sebaceous glands and hair-follicles; and, finally, breaking 
up into smaller and yet smaller branches, furnish a single or double 
capillary loop to each papilla. The capillaries of the papillary layer 
anastomose freely with those transversely arranged in the upper 
portion of the hair-follicle, loops from which also pass to the seba- 
ceous glands. The hair-papilla has a vascular supply similar to that 
of the other papilla of the corium. 

Unna divides the vessels distributed to the skin into the papillary 
system, and the system of the coil-glands and fat tissue. The former 
includes the ascending loops which traverse the vascular papillae, and 
the branches supplying lower portions of the corium. The latter 
embraces the vessels running upward to the coil-glands and down- 
ward to the fat tissue. In the papillary vascular system, the arteries 
are narrow and the veins wide. The vessels consist merely of an endo- 
thelial tube augmented, as the subcutaneous tissue is reached, by both 
media and adventitia. According to Hover, there is a singular duplex 
arrangement of vessels in the distal phalanges of both fingers and 
toes, in consequence of which there is a direct communication between 
the arteries and veins. 

Vasomotor nerves are twined around these vessels in all their 
ramifications. The whole vascular system, as thus arranged, plays a 
most important part in all the healthy and morbid processes which 
occur in the skin, as well as in the sudden physiological changes dis- 
tinguishable to the eye in the phenomena of blanching and blushing. 

Lymphatic Vessels. 

The skin in all its parts is provided with a system of lymphatic 
channels, designed to subserve the necessities of the important pro- 
cesses of absorption, and traversed by lymph whose currents are 
continuously directed to the large vessels of the structures beneath 
the skin. Unna divides these channels into : first, juice-spaces, pro- 
vided or not with independent walls, usually the latter, and not freely 
communicating with the endothelium-lined vessels; second, lymphatic 
vessels proper, which communicate directly with the bloodvessels. 

The juice- or lymph-spaces separate the epithelial bodies that make 
up the stratum mucosum of the epidermis, and also extend between 
the protoplasmic threads or prickles that unite them. Such conduits 
may be regarded either as delicate excavations in the so-called cement- 
substance between the epithelia, or as irregular chanuels in a softish, 
viscid, albuminoid, and readily coagulable substance existing between 
the protoplasmic threads. In the latter event, these spaces would be 
comparable to the impression's made by thrusting at random a pencil 
into a mass of soft putty. At times, this intercellular substance 



NERVES. 29 

seems capable of obstructing the conduits by which it is tunnelled. 
These same juice-spaces exist in the papillae of the corium, and 
encircle the different glands, hair-follicles, and nail-beds of the skin. 
They also sheathe the connective-tissue fibrillse of the corium and 
surround the fat-cells. 

The lymphatic vessels are relatively few, but form a continuous 
mesh work with transversely and vertically disposed branches sup- 
plying all parts of the skin below the epidermis. The juice-spaces 
communicate with these vessels in the papillary portion of the corium 
through minute orifices in the vascular walls, the vessels themselves 
being here represented by blind terminal loops. As they pass to the 
deeper portions of the corium and below it, these vessels increase in 
size. 

The current of the lymph is from the papillary apices in every 
direction to all parts of the rete, like the currents in the delta of a 
river, a reflux occurring at the lower limit of the interpapillary 
depressions of the rete downward, possibly through the sweat-pores 
which traverse the epidermis at these points. Thence the current 
flows freely downward to the lymphatic vessels in the corium, but 
the stream from the juice-spaces about the coil-glands and fat tissue 
is retarded by reason of a more restricted communication with the 
lymphatic vessels below. In consequence of the retardation due to 
this anatomical peculiarity, the formation of fat by filtration is 
facilitated. 

Nerves. 

Non-medullated and medullated nerve-fibres, each in places being 
substituted for the other, are supplied to the skin from horizontally 
disposed bundles of nervous twigs iu the subcutaneous tissue. These 
traverse the corium in connection with the bloodvessels, and become 
finer as they ascend, till they form a subepithelial plexus just below 
the epidermis. 

Exceedingly delicate Nox-medullated Fibres penetrate to the 
epidermis between the epithelia in great abundance. Here, traversing 
the intercellular substance by the side of the juice-spaces, they either 
terminate between the prickle cells as ultimate bulbous terminations 
of finely beaded fibrillse, or they penetrate the epithelia themselves 
in pairs. Each prickle-cell is supplied with a pair of these beaded 
filaments, which may be either applied to the nucleus of the cell, or 
be seen to encircle the nucleus more or less completely. Above the 
stratum granulosum these nervous threads cannot be recognized. 

Similar nervous filaments are supplied to the sheaths of the hairs 
and the ducts of the coil-glands. It is by means of these numerous 
and delicate fibres that the perception of sensation in the skin is 
accomplished. 

Motor filaments, discovered by Thomsa, are also distributed to the 
sheaths of the bloodvessels, in which they are finally lost. Other 
motor filaments supply the muscles, and trophic nerves are distributed 



30 



ANATOMY AND PHYSIOLOGY OF THE SKIN 



to all the secreting organs of the skin, and to all its protoplasmic 
fori nations. 

The Medullated Nerve-fibres of the skin have been care- 
fully studied by Dr. A. R. Robinson, 1 of New York. According to 

the latter, one or several loops of such fibres pass upward into the 
papillae, and then turn backward to the subpapillary region. Some 
of these, alter such reversion, again ascend to an adjacent papilla. 
Yet others are supplied to the Pacinian and tactile corpuscles. 

The Pacinian Corpuscles, named from the anatomist Pacini, 
also called Corpuscles of Vater, exist subcutaneously only upon 
nerves intended for cutaneous supply, and are small, oval bodies, two 
or more millimetres in diameter. Each consists of a series of con- 
centric, nucleated, and vascular capsules, arranged after the manner 
of the capsules of the onion, more closely united at the periphery 




Pacinian body, after silver staining, 
showing sui>c'i'iiii]iuseil endothelial lay- 
ers. (After Renaot.) 



Section of Pacinian body, from a duck's bill. g.L, 
lamellar envelope ; y.h, hyaline zone of the lamel- 
lar envelope ; bt, terminal bull) of the nerve ; y.p, 
u.g.p, layer investing the cavity of the body. (After 
Renaut.) 



than at the centre, and surrounding a protoplasmic core. The medul- 
lated nerve to which the body is attached gradually loses its myeline 
envelope, and terminates in the centre of this core, after traversing 
the greater part of its axis, in one or several, minutely club-shaped, 
nervous filaments. The myeline sheath is lost in the tissue of the 
concentric capsules. According to Ranvier, the nerve may, after 



of Dermatology, by A. K. Robinson, M.B., etc New York, 1884. 



JSTEKVES. 31 

supplying one capsule, subsequently penetrate a second, or even a 
third. In such cases the nerve regaius its sheath as it issues from 
the corpuscle at its opposite pole. Robinson believes that the nerve 
forms a plexus or loop within the corpuscle, and again leaves it at 
one of its poles. 

The precise function of the Pacinian corpuscle is unknown. Its 
connection with the tactile sense is suggested by its location, since 
these bodies are most numerous in the subcutaneous tissue of the 
nipple, the penis, the digits, and parts similarly sensitive. It bears 
an evident analogy to the organ of vision, each body having a cap- 
sular character ; each being provided with a special nerve-filament, 
which enters the corpuscle at one pole ; each also receiving its im- 
pressions at the extremity of the capsule opposite that where it 
receives its nervous supply. 

According to Krause, the Pacinian corpuscles are concerned in 
the appreciation of impressions produced by pressure and traction. 
Whether specially concerned in the distinguishing of sensations 
originating in heat, cold, moisture, pressure, traction, or weight, it is 
evident that they contribute but little, if at all, to the reception of 
ordinary impressions upon the skin, and, at this date, they are not 
known to play any part in cutaneous diseases. 

The Tactile Coepuscles (Corpuscles of Meissner, or Wagner) 
(see Fig. 5) are other oval-shaped bodies found in about one of four 
of the papilla? in the pars papillaris of the corium. They are com- 
posed of from one to three capsules, each receiving a medullated 
nerve-fibre and made up of closely compressed, flat, connective-tissue 
fibres with minute nuclei, which are so packed together as to form a 
spindle-shaped mass, occupying the greater part of the papilla in 
which each is found. A somewhat denser connective-tissue capsule 
encloses each. The myeline sheath of the nerve-fibre is lost in the 
fibrous tissue of the corpuscle. Externally viewed, they seem to be 
transversely striated. 

The axis-cylinder of the nerve-filament distributed to each divides 
into numerous delicate nervous threads which in part encircle the 
corpuscle and also penetrate within. According to Dr. Robinson, 
each corpuscle is provided with an afferent and efferent nerve, the 
former approaching the corpuscle from the subpapillary region and 
entering at or near its base. Occasionally the afferent fibre is fur- 
nished by an adjacent papilla. As the filament that enters the 
corpuscle frequently divides, two or more efferent fibres may then 
escape from it. 

The discovery of nervous filaments in and among the epithelia of 
the epidermis in such abundance as to provide fully for tactile sensa- 
tion in the skin, leaves the exact function of these corpuscles in 
partial obscurity. There can be little doubt, however, as to their 
association with the perception of certain qualities of foreign bodies 
with which the skin may be brought into contact. 



32 AX ATOMY AND PHYSIOLOGY OF THE SKIN 



Pigment. 

The hue of the living integument is due in part to the degree of 
vascularity and distention of the vessels in the coriura, and in part 
also to pigmentation of the epidermis. Tin's pigmentation depends 
upon a distinct and uniform coloration of the epithelia, chiefly those 
found in the lower strata of the epidermis, and also to minute 
granules of pigment entangled in the reticulum of living matter in 
the same parr. Extreme variation in the distribution of pigment is 
noticeable both in health and disease, and in individuals and races, 
being, at times certainly, proportioned to climatic and similar influ- 
ences. This is well illustrated by the wide range between the flaxen- 
haired and pink-eyed albino, and the blackest specimens of the negro, 
each with small exception of African descent. 

It has been already noted that in the colored races the pigment 
may stain the epithelial cells and their nuclei, as high as the granular 
layer; and that to this layer only the peculiar color of the skin of 
the white races is due. Pigment is not found normally either in the 
horny layer of the skin or in the subepithelial tissues. Waldeyer 
alone claims to have recognized it in normal connective tissue. 

The relation existing between the two sources of skin coloration, 
viz., the blood and the pigment, is interesting and suggestive. The 
eye unaided, looking at the outer surface of the body, makes no dis- 
tinction between these two color sources. It is indeed probable that 
the pigment originates from the coloring matters of the blood. It is 
certain that solar heat exerts a manifest influence upon both, and 
that in extravasations of blood into the substance of the skin, every 
shade of color which can be detected in the spectrum can be at times 
distinguished. 

Muscles. 

Striated Muscular Fibres extend from the subcutaneous tissue 
into the derma, and in the case of man are found chiefly upon the 
face and neck, where they are the analogues of more powerful skiu- 
moving muscles possessed by several of the lower animals. Some, 
as those in the region of the face, serve to give expression to mental 
emotion by the production of movements in the features. 

Non-striated Muscular Fibres exist either as minute oblique 
fasciculi in connection with glands and follicles of the skin; or as 
annular bands, such as those which surround the uipple; or as 
radiating and more or less parallel rods, such as antagonize the orbicu- 
laris in the lids. 

The Arrectores, or Erectores, Pilorum are muscles usually 
found in connection with the hair-follicles. They originate by 
several minute fasciculi from the papillary portion of the corium, and 
are inserted at several points into the outer layer of several adjacent 



HAIRS. 33 

hair-follicles, just above the plane of the apex of the hair-papilla. 
Their general direction is oblique, and their muscle-bundles are both 
embraced and traversed by elastic fibres which form a dense network 
about them. Elastic threads also connect them intimately with the 
connective-tissue bundles of the corium, and serve as tendons at 
either extremity of each muscular fasciculus. 

The oblique direction and mode of attachment of these muscles 
result in their inclusion of the sebaceous glands connected with the 
hair- follicles in the angle subtended by their muscular fibres. It 
follows, therefore, that by their contraction they can aid in the 
expulsion of the sebaceous secretion formed in the gland. But their 
intimate union with the elastic tissue, which is evenly and generally 
distributed throughout the framework of the corium, results in their 
discharge of a still more important function in connection with the 
regulation of the bodily temperature. Their anatomical connections 
are such that contraction of the arrectores pilorum serves to approxi- 
mate several of the papilla? of the corium, the hair-papilla being in 
this view regarded as one of such cones. Thus, by their contraction 
the sebaceous secretion may be extruded, or, as more particularly 
exhibited in the lower animals, such hairs may be erected as the 
bristles of the boar. But by virtue of direct compression exerted 
upon the skin, the blood may be driven from the surface in a centri- 
petal direction and its cooling to a great degree prevented, as in the 
well-known phenomena resulting in the production of the cutis 
anserina or " goose flesh." The reverse of this naturally follows 
when the muscles expand under the influence of external heat. 

Hairs. 

Hairs are cylindrical, elongated, and pointed epithelial filaments, 
derived from the epidermis, and obliquely implanted in depressions 
in the rete and corium, known as hair-sacs, or hair-follicles. They 
are found in all portions of the body except the palms and soles, 
the dorsum of the distal phalanges of the hands and feet, and the 
skin of the penis. Hairs occur in three tolerably distinct classes. 
There are the fine downy hairs, or lanugo, covering the face, trunk, 
and limbs ; the long and soft hairs, such as are implanted upon the 
scalp, pubes, and axillae ; and the short hairs, including the soft 
varieties seen upon the brow, and the stiff hairs of the lids. 

The hairs are first developed in the third month of foetal life, 
when a short epithelial cone is formed, whose base is gradually 
surrounded by connective-tissue cells, and finally indented from 
below by a rudimentary hair-papilla. Gradually the tip of the 
rudimentary hair perforates the primitive hair-cone, and becomes a 
mature filament. 

At about the period of birth, sometimes earlier, occasionally 
later, the bed-hairs, as they are called by Unna, are replaced by 
papillary hairs. The term bed-hair is applied to primary hairs 
unprovided with papilla?, and implanted in shallow follicles from 



34 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



the sides of which productive epithelial offshoots have been sent 
out. Usually at the end of foetal life these bed-hairs have been 



Fig. 9. 



Fig. 10. 







Jv 



/"I 









mm 



v 






Section of hair-follicle during the formation 
of a new hair, a, external and middle root- 
sheaths ; b, vitreous membrane ; c, papilla, with 
vascular loop ; c/, external root-sheath ; e, in- 
ternal root-sheath;/, cuticle of hair-follicle; 
g, cuticle of hair ; h, i, young hair ; /, bulb of 
old hair ; it, debri6 of external root-sheath of 
hair recently expelled. (After Ebnee.) 



Hair-follicle in longitudinal section, a, mouth 
of follicle ; I, neck ; c, bulb ; d, e, dermic coat ; 
/, outer root-sheath ; g, inner root-sheath ; h, 
hair; k, its medulla; 1, hair-knob; m, adipose 
tissue ; n, hair-muscle ; o, papilla of skin ; p, 
papilla of hair ; s, rete mucosum, continuous 
with outer root-sheath ; ep, horny layer ; t, seba- 
ceous gland. 



for two months growing out of the hair-bed, or that part of the 
epithelium found in the central part of the hair-sac. 

In studying the mature hairs, the parts to be considered are the 
hair-follicle, and the bulb, shaft, and point of the hair. 



HAIRS. 35 

Hair-follicle. — The hair-follicle is a sac-like depression in the 
corium, in which the hair-filament is implanted by its bulb, and 
there firmly secured. The direction or set of this follicle is always 
at an oblique angle with the plane of the cutaneous surface where 
it opens; and thus is determined the set of the hairs, which is 
always fixed, and at a similar angle. Viewed as a whole, the 
integument of the body over its entire area exhibits determinate 
whorls of both short and long hairs with definite centres, such as 
those which may be recognized at the vertex of the scalp, the centres 
of the lips, the umbilicus, etc. By this disposition the symmetrical 
appearance of the hairy parts is preserved, and, as a consequence of 
the same provision, physiological loss of the hair of the head is 
not productive of deformity, but rather adds dignity to the aspect 
of the elderly man. 

The hair-follicle embraces the lower two-thirds of that portion of 
the hair which is embedded in the skin, together with the envelopes 
of the latter, termed its sheaths. Above the sebaceous glands the 
limits of the hair-follicle are lost in the papillary layer. It is con- 
stituted of the connective tissue of the corium in three layers : an 
external, longitudinal, fibrous layer; a middle, transverse layer; and 
an internal, homogeneous, or vitreous layer. At the base of the 
sac a fibrous pedicle may often be traced as low as the subcutaneous 
tissue. 

If the hair-pouch were made artificially by thrusting into the skin 
from without inward a blunt-pointed pin, before which the tissue 
was gradually pushed, it is evident that the external layer, the 
stratum corneum, of the epidermis would be the first depressed, and 
finally cover the inner surface of the pouch. This represents the 
inner root-sheath of the hair. Next to this the pin would carry 
before it the mucous layer of the epidermis, which then would form 
the outer root-sheath of the hair„ Outside of both would lie the 
connective tissue of the corium ; this is the hair-follicle. 

The Outer Root-sheath, or, as Unna prefers to call it, the 
prickle-layer of the hair-follicle, accompanies the involutions of the 
stratum corneum, and the stratum granulosum from without, into the 
funnel-shaped neck of the hair-pouch as far as the openings of the 
ducts of the sebaceous glands. There, abandoned by the two other 
layers of the epidermis, it is thinned in proportion as the papilla, 
which rises from below and which it closely surrounds, increases in 
size. It thus forms a hollow^ cylinder traversed by the hair and its 
envelopes, with a relatively wide, external, funnel-shaped opening, 
only partially filled by the shaft of the hair, and a narrower opening 
within, which embraces the neck of the hair-papilla. 

The Inner Root-sheath, or, as Unna prefers to call it, the 
matrix of the root-sheath, is externally in relation with the outer 
root-sheath or prickle-layer of the hair-follicle. The protoplasm of 
the cells of which it is constituted contains kerato-hyalin in varying 



36 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



quantities, the amount being naturally greater in the cells lying 
Dearest the hair-filament. The part of the sheath formerly termed 
Henle's layer is the more externally situated, cellular envelope of 
this interna] root-sheath, most conspicuous in that part ol the hair- 



FlG. 11. 



- 







M> 







Lower portion of hair-pouch from the lip of akitteu. F, follicle; T, transverse sections of con- 
nective-tissue bundles of derma ; M, arrector plli muscle ; IS, inner root-sheath ; OS, outer root- 
sheath ; P, papilla ; C, cuticle ; R, root of hair ; H, hyaline, or so-called structureless membrane. 
Magnified 500 diameters. (After Heitzmann.) 



sac which is above the level of the papilla. That part of the sheath 
formerly called Huxley's layer, is the more internally situated part 
of the same sheath, somewhat higher in the follicle. Both of these 
terms are now falling into desuetude as not actually descriptive of 
distinctly different structures, but only of one structure in different 
situations. That structure, whether it is termed the internal root- 
sheath, or matrix of the root-sheath, springs from the neck of the 
papilla, and rises as high as the neck of the follicle. It contains 



HAIRS. I 37 

kerato-hyalin, which is actively concerned in the cornification of the 
hair tissue. 

Between this structure and the cells constituting the cortex of the 
hair, there is found, according to Unna, the common matrix of the 
cuticulee, forming respectively the cuticle of the root-sheath, and the 
cuticle of the hair. The former is composed of cells with their long 
axes parallel to the circumference of the hair, while those forming 
the cuticle of the hair are arranged perpendicularly to the surface. 
These cuticulse are securely locked together by projection of their 
cell edges, while united in the hair-follicle. 

The Bulb, or Root, of the hair is that portion which is embedded 
in the skin, toward which the shaft of the hair gradually increases in 
thickness as it descends. It is embraced by the hair-follicle, though 
its root-sheaths are interposed, and implanted below at the base of 
the sac upon a nipple-shaped prolongation of the corium, which may 
be regarded as analogous to the vascular papillae of the papillary 
layer of the corium. 

The bulb of the hair embraces the papilla, and is constituted of 
pigmented cells externally, forming what is called the cortex or 
cortical portion. This is the larger of the two structures of wdiich 
the hair is composed, and its cells become vertically elongated and 
narrow as they are pushed outward in the process of growth. 

The innermost structure of the hair is called its medulla, a tissue 
composed of non-pigmented, horizontally broadened cells containing 
kerato-hyalin. It rests directly upon the 
. apex of the papilla below, and passes Fig. 12. 

thence through the centre of the shaft of ,-<^~T~^ HH^ 

the hair like a delicate cylindrical core. / ■••^^^''" ; ^■-■"^ f!? ^^'' : ■. 

Air-spaces occur between its epithelial . ' - \ . * 

cells as it rises toward the funnel-shaped , /-- \ ' 

opening of the hair-sac, but air does not 
enter the body of the individual cells. 

ill 
The Shaft of the Hair is that \ 

portion which extends from its exit at the I 

surface of the skin to its extremity. The , \ ; ,4 - 

latter, when uncut, always tapers to a \ • •.' ' 

perfectly acuminate point, as is illustrated 

in the uncut hairs of the lids, and of the 

lower animals. The shaft is either straight, Tr 

curled, wavy, or alternately varied in follicle. 

diameter, producing the peculiar character 

of the growth seen upon the scalp of the negro, these variations being 

due to the different degrees of flattening of the shaft in a transverse 

direction. 

The color of the hair is dependent upon the pigment it contains, 

the proper color of the hair-cells, and the quantity of air contained 



section of hair and 



38 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

iii the medulla. Variation in these three factors produces the wide 
range between a snowy whiteness and an ebony black. 

The membrane which invests the shaft of the hair is the cuticle, 
already described, composed of numerous flattened plates, regularly 
overlaid so as to resemble fish-scales when viewed under the micro- 
scope on the Hat side, and the overlapping shingles of the roof of a 
house when seen on the edge. 

The Cortical, or main, Substance of the Shaft of the hair 
is here also enwrapped by the cuticle, and composed of flat, nucleated, 
fusiform, epidermal cells. The strength, elasticity, and extensibility 
of the hair are chiefly due to the cortical substance, and in particular 
to the firmness with which these epidermal cells are attached to 
each other. 

The Medullary Substance of the Shaft of the hair is 
found best developed in the short and strong hairs of the beard and 
eyelashes, being wanting in the lanugo hairs. It consists of a loosely 
packed mass of epidermal elements, differing in shape, developed in 
the centre of the axis of the shaft. This part of the hair contains 
also the pigment and fatty matters which are here arranged as in the 
rete of the epidermis. Seen under the microscope,' the medulla 
appears as a continuous or interrupted longitudinal band, extending 
from the bulb, or the part implanted in the follicle, to the extremity 
or point. The purpose of this difference in the constitution of the 
cortex and medulla of the hair is doubtless to insure, on well-known 
mechanical principles, a maximum of strength, extensibility, and 
elasticity, with a minimum of volume. 

The coloring matter of the hair is stored in both its horny and 
medullary portions, and is distinct both within and between the 
epithelial elements of which it is composed. This pigmentation cor- 
responds, as Heitzmaun has shown, in great part to the amount of 
pigment distributed to other parts of the integument, and sustains a. 
close relation to the general nutrition of the body. Its subjection to 
the influence of the trophic nerves is well demonstrated by the phe- 
nomena of rapid blanching of the hairs. Excessive sweating, whether 
physiological or induced by the action of pilocarpine, has also a 
distinct influence upon the shade of color of the hair. 

On transverse section hairs present an ovoid or ellipsoidal outline, 
occasionally suggesting an irregularly compressed circle. The degree 
of this flattening differs in different races, and, as has been shown, . 
i> the cause of variability with respect to straightness or curliuess. 
As hair- are to a marked degree hygroscopic, and not only absorb 
but can be deprived of a portion of their water, these states of 
waviness are subject to variation according to the aqueous condition 
of the media by which an individual is surrounded. 

Hairs differ from nails not only in their anatomical features, but 
particularly as to their physiological reproduction. The former are 
periodically cast off and replaced by new filaments; the latter are so 



SEBACEOUS GLANDS. 39 

shed and reformed only in disease, and in health enjoy a continuous 
growth during the life of the body. 

When a hair is about to be shed it separates from its papilla in the 
hair-follicle and rises in the latter till it reaches above the level of the 
papillary apex. It is thus for a time held in place with sufficient 
firmness by the prickle-layer only, and thus forms the bed-hair de- 
scribed above. Later an epithelial bud is projected either into the 
vacant follicle below or into the corium on either side, from which a 
new hair is formed, somewhat as the hair is formed in the primitive 
cone of foetal life. Later the growth outward of the new papillary 
. hair pushes the bed-hair from its connection with the prickle-layer, 
and the latter is shed. 

Sebaceous Glands. 

The sebaceous glands are pyriform bodies, usually racemose in 
development, situated in the corium, never in the subcutaneous tissue, 
which furnish a more or less consistent and fatty secretion destined 
to anoint the skin and hairs. They can be usefully distinguished as 
in three separate classes, though only two of these classes include 
glands which are in the embryo associated with hairs. 

The first class, as proposed by Sappey, includes the sebaceous glands, 
which are, strictly speaking, appendages of the hairs and hair-folli- 
cles. They are developed early in foetal life from minute, lateral, 
bud-like prolongations from the outer root-sheath of the hair. From 
two to six of these spring from the prickle-layer of the hair-follicle ; 
and the prickle-cells in the axis of each bud speedily undergo fatty 
metamorphosis. In the mature gland each acinus is formed of a 
membrana propria, on which are ranged layers of nucleated cuboidal 
epithelia undergoing fatty metamorphosis. Gradually the fatty cells 
are pushed outward toward the duct of the gland, where, sooner or 
later, their rupture releases numerous drops of fat just where the hair 
emerges from the closely applied follicle below to the funnel-shaped 
mouth of the hair-pouch above. Externally, each gland is provided 
with a layer of connective tissue. On account of the clearly defined 
relations of these bodies, Unna would call them the "glands of the 
hair-follicles." They are found in connection with the long and soft 
hairs, as of the scalp and axillae, several grouped around a single 
hair-sac. 

The second class includes the large and complex glandular struc- 
tures to which the lanugo, or rudimentary hairs, seem accessory, the 
orifice of their ducts opening directly upon the cutaneous surface. 
These are chiefly found upon the so-called non-hairy portions of the 
skin, as the face in both sexes, and portions of the trunk and extrem- 
ities. 

The third class includes much the smaller number. These are 
sebaceous glands opening directly upon the surface and unconnected 
with hairs or hair-follicles. Such are the glandulse odoriferse of the 
male and female genitalia (glands of Tyson), the Meibomian glands, 



40 



ANATOMY AND PHYSIOLOGY OF THE SKIN 



and those existing about the lips and in the areola of the nipple. 
These might be designated as the "glands of the mucous orifices." 



Flo. 13. 






\ 



r} ,*?&=* *» 



_JiF '$ 



•v 



Sebaceous glands of the second class from the alse of the nose. (After Sappey.) 

The sebaceous secretion is found to contain, chemically, water, pal- 
mitic and oleic acids, palmitin and olein, soaps, and the saline constit- 
uents of the other organic animal compounds, chlorides and phos- 
phates of the alkalies and earths. It has been already shown that 
the extrusion of the secreted sebum from the ducts of these glands 
is greatly favored by the action of the arrectores pilorum muscles, by 
whose contractions the gland is to a degree compressed. This is the 
reverse of what occurs in the coil-glands, whose secretion is impeded 
by the action of these same muscles. 



Coil-glands. 

The Coil-glands, also termed Sweat, or Sudoriparous 
glands, are globular coils situated in the subcutaneous tissues and in 
the deeper portions of the corium. They appear first in the fifth 



COIL-GLANDS. 



-11 



month of foetal life as buds projected downward from the prickle- 
layer of the epidermis. Unna has demonstrated that these projections 
always form between the papillae of the corium, and spring from the 
prolongations of the rete between these papillae. Long, thin cones 
of epithelium thus gradually traverse the corium, and become slightly 
bulbous at the lower extremity to form later the coil. The lumen, 
when formed, extends rapidly to the epidermis, and after this is 
reached, an opening is made from within outward, which becomes 
the sweat-pore. 

These glands after birth are found in all parts of the body, but in 
certain regions, such as the axilla?, the groins, the palms, the soles, 
and about the anus, they are either numerous, of unusual size, or 
peculiarly arranged. They are specially numerous in the palms and 
soles, where, according to Krause, there are between two and three 
thousand to the square inch. 



Fig. 14. 




Coil of the sweat-gland. S, tubule lined by cjiboidal epithelia ; T, central calibre of the tubule ; 
D, beginning of the duct ; C, connective tissue with injected bloodvessels. Magnified 500 diameters. 
(After Heitzmann.) 



The coil is a convoluted tube terminating in a coecal pouch, lined 
with cubical epithelia of granular appearance which are the secretory 
cells of the gland. Outside of these are muscular fibres running 
parallel with, or in a spiral direction about the coil. Surrounding 
both muscle-bundles and epithelium is a connective-tissue membrane. 
The glomerulus, or coil, is globular in outline and reddish-yellow in 
color. In the larger glands irregular dilatations and constrictions of 
the tube are conspicuous. 

The excretory duct of the coil-gland passes from the glomerulus 
below to the epidermis above, in a straight or spiral course. It is 



-12 ANATOMY AND PHYSIOLOGY OK THE SKIN. 

lined with a delicate hyaline cuticle discovered by Reynold, beneath 
which is a double layer of cuboidal epithelium. Externally is a mem- 
brana propria, unprovided with muscular fibres. Its outermost 
sheath is the usual connective-tissue layer. When the duct reaches 
the border-line of the epidermis, its inner cuticle and external connec- 
tive-tissue sheath are both lost, Here it becomes the sweat-pore. 




-TL 




The sweat-pore traversing the epithelial layers of the skin. /;/', papilla wilh injected blood- 
vessels; F, yuI ley between two papillae: D, duct in the rete mucosum ; E, E, epidermal layer ; PL, 

coarsely granular epithelia, deeply stained with carmine ; P, duct with corkscrew windings in the 
epidermal layer. Magnified 200 diameters. (After Heitzmann.) 

The Sweat-pore is a continuation of the excretory duet of the 
coil-gland after the loss of its cuticle and connective-tissue sheath. It 
is the loss of these sheaths and the consequent intimate relation of the 
canal to the epithelia of the epidermis that furnish the special basis 
for this distinction. The sweat-pore is merely a wall-less canal or 
channel, spirally directed or running a straight course from the duct 
of the coil-gland below to the outermost stratum of the epidermis 
above. It has no other wall than that formed by the cells of the 
prickle-layer below and of the other layers of the epidermis, which 
successively surround this canal, narrow below and funnel-shaped 
above. Hence the lumen of the sweat-pore, if such a term be per- 
missible, is in free communication with the juice-spaces of the epi- 
dermis. 

The secretion of the coil-glands consists largely of globules of fat 
and granules of pigment. Their function, therefore, is plainly the 
lubrication of the skin with unguent, a task performed only in small 
part by the sebaceous glands, and by them chiefly for the pilary 
covering of the body. The palm- of the hands an 1 the soles of the 
feet, where no 3ebaceous gland- exist, are thus lubricated with fat by 
the coil -glands. 



COIL-GLANDS. 43 

The total number of the coil-glands in the body is estimated to be 
between two and three millions, and the total length of the uncoiled 
glands about eight miles. These figures serve to give an approximate 
idea of their very great physiological importance, and of the extent 
to which violation of the rules of hygiene possesses interest from the 
pathological point of view. 

The function of the sweat-pores, which communicate directly with 
the excretory duct of the coil-glands, is distinct from that of the coil- 
glands, since it provides for the transmission outward of the watery 
fluids of the skin. The channel described as the sweat-pore is in 
ample and free communication with the intercellular spaces of the 
epidermis ; and this anatomical peculiarity provides fully for all the 
needs of evaporation at the surface of the body. 

The sweat excreted by the body differs under varying conditions of 
Temperature, humidity of the air, and the amount and character of 
the articles ingested by the individual, either as food, drink, or 
medicament. Nearly ninety-eight per cent, of the secretion is pure 
water, the remaining proportions representing the saline constituents 
of the other fluids furnished by the animal in life. In all chemical 
analyses of the sweat, a source of error lies in the difficulty of securing 
the fluid secretion unmingled with that produced by the sebaceous 
glands; and the same, it may be said in passing, is true of the chemical 
analysis of the sebum. According to Duhring, the iodide of potas- 
sium, benzoin, succinic and tartaric acids may be excreted with the 
perspiration. 

Unna, following in the line first indicated by Meissner, asserts that 
the coil-glands actually produce the subcutaneous fat-cushion ; and 
the anatomical basis of such a statement is clear. The coil-glands 
and the fat-cushion appear at the same period of foetal life and develop 
in the same proportions. At birth the clusters of fat are most con- 
spicuous where the coil-glands are most numerous. In the adult, 
the greater number of coil-glands are subcutaneous in situation and 
are closely surrounded by fat tissue ; while those glands which do 
not descend below the corium, though not thus surrounded, are 
regularly met by columns of fat advancing toward them from below. 

The credit of discovering and naming these fat columns belongs to 
Dr. J. Collins Warren, of Boston, whose studies were principally 
directed to the anatomy of the thick cutis vera. 1 The back and 
shoulders of a vigorous adult furnish an integument much thicker 
than the hide of many pachydermatous animals. The papilla? are 
imperfectly formed, and represented by an undulating line. The 
follicles of the lanugo hairs penetrate only the superficial layers of 
the cutis. From the bases of the hair-follicles, nearly vertical clefts, 
or slender, columnar-shaped spaces, extend obliquely to the panniculus 
adiposus, which were fitly termed by Warren, "fat-columns or fat- 
canals," as they are entirely occupied bv adipose tissue. (See Figs. 
3 and 4.) 

These columns are about four mm. in length, and are slightly 

i Satterthwaite's Manual of Histology, p. 420. New York, 1881. 



44 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

wider than the hair-follicles above. Their long axes form a .slight 
angle with that of the follicle, but they are nearly parallel to that of 
the erector pili muscle. Two horizontal prolongations arc given off 
on either side of the mid. lie of this axis, partly fat-filled. Near this 
point Dr. Warren called attention to -'the coil of a sweat-gland, held 
in place by a few delicate fibres." The duct of the gland runs to 
the top of this space, whence it may be traced to the side of the hair- 
follicle. The connective-tissue fibres seem to terminate abruptly at 
the edges of these columns. The cleft slightly widens below, and on 
the side toward which its axis leans the fibres of connective tissue 
form a bundle penetrating below to the subcutaneous fat. The 
erector pili muscle is inserted partly into the base of the follicle and 
partly into the apex of the fat-canal. 

These columns correspond in number to the hairs. The blood- 
vessels which they contain, springing from the subcutaneous plexus, 
bifurcate at the lateral clefts. 

The later studies of Unna demonstrate very clearly that the fat- 
columns, first recognized by Warren, invariably advance toward the 
coil-glands, the latter either singly or in groups; and that the con- 
nection of the fat-columns with the hair-follicles is a mere incident of 
that advance. 

The alternation of muscular fibres with the secretory cells of the 
duct of the coil-gland is a provision for the extrusion of the gland- 
secretion onward. The same anatomical arrangement permits free 
communication between the epithelia and the lymph-spaces which 
reach into the connective-tissue sheath of the gland. As a result, the 
lymph Hows freely among the secreting elements of the gland and its 
duct. This lymph, loaded with fat, streams away from the coils, and 
before it reaches the lymphatic trunks its fat-globules are filtered away 
in the subcutaneous tissue. Such is the interpretation of this rela- 
tionship by an author whose studies of the mutual interdependence of 
the several component parts of the integument have furnished the 
most interesting and fruitful results. 

The Odorous Emanations from the Skin. 

The skin of the human body in health is the constant source of 
odorous emanations, which, in pathological conditions, may be greatly 
increased or otherwise changed. The nature and exact sources of 
these emanations are as yet imperfectly understood. Were these ex- 
clusively of a volatile, gaseous, or vaporous composition, even though 
such fluids were capable of condensation upon external bodies, this 
could scarcely explain the well-known fact that some of the lower 
animals are capable of tracing the track of the human being for miles 
over a wind-swept path, till the soil pressed by the foot is covered 
with water. There is strong reason to believe that these emanations 
are the sole sources by which some contagious and infective diseases 
are communicated from oik 1 individual to another, a fact which 
suggests that these emanations may at times contain living matter 



THE NAILS. 45 

•derived from the protoplasmic masses of which the body is built up. 
These emanations are properly regarded as having their origin in 
the secreting system of the skin, but in what proportion the several 
secreting glands participate in the product is difficult to establish. 
The sweat at times, even to human nostrils, exhales a distinct odor, 
though, as before indicated, to what extent this is due to its admixture 
with the sebaceous material it is difficult to determine. Peculiarly 
fetid and disgusting odors occasionally originate in chemically altered 
sebum, where the influence of the sweat secretion must be, from the 
locality under examination, partly eliminated. 

The Nails. 

Nails are dense, elastic, and translucent concavo-convex plates, or 
shells of horny tissue, placed upon the dorsum of the terminal 
extremities of the distal phalanges of the fingers and toes. Each has 
a free border at the distal portion of the pulp of the digit, with sides 
and proximal borders let into distinct furrows of the skin. The 
convex surface of the nail is exposed, the concave regarding the 
phalanx, and being implanted upon the nail-bed beneath. 

In the embryo the first change looking to the future formation of 
a nail consists in a peculiar smoothness and brilliancy of the 
epidermis covering the dorsum of the distal phalanges. Later, an 
epithelial ridge or line with a groove in front of it traverses the tip 
of the finger. Thus, three regious are defined : that behind the ridge, 
the nail-wall ; that in the groove, the nail-bed ; and that in front of the 
groove, the pulp of the last phalanx of the digit. A collection of large 
prickle-cells at the orifice of the nail-fold soon furnishes the first trace 
of the rudimentary nail. Mature nail-cells finally push forward 
between the prickle and horny layers of the nail-bed, which, by fan- 
shaped bundles of follicles, is firmly united to the periosteum of the 
phalanx. Lastly, a thin plate of horny material with a free edge, is 
visible externally in the fingers and toes of the newborn child. 

In the adult, what is termed the matrix of the nail, is the tissue 
from which the horny plate springs. It is separated, as shown by 
Hans Hebra, into, first, a posterior part, filled with from three to 
six rows of papillfe. Next, in advance of this, is a lenticular space 
with curved borders, the anterior limit of which corresponds to the 
anterior border of the lunula. The area included in these two divi- 
sions is provided with papillae grouped in symmetrically converging 
ridges, decreasing in size as they pass forward. This forms the 
matrix of the nail. Further forward, the nail-bed proper — in other 
words, the tissue that supports, rather than produces the horny plate 
— is composed of higher ridges of papillae whose grooves and summits 
are covered with prickle-cells, and whose height is uniformly main- 
tained as they stretch forward toward the pulp of the fiuger. 

Attention has been already called to the fact that the digital arteries 
communicate directly with venous spaces and veins in the nail-bed, 
an anatomical peculiarity demonstrated by Hoyer. This arrangement 



46 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

evidently provides for the safety of these slender and exposed organs 
in conditions arresting temporarily either the venous or the arterial 

current. 

Fig. in. 

d 



e .j* 



Vertical section of one-half of nail and matrix, a, nail substance ; b, horny layer ; <-, mucous layer; 
,1. papillae of corlum ; e, nail furrow destitute of papillae ; /, horny layer of the ungual furrow rising 
above the nail ; g, papilla? of skin of dorsal surface of the finger. 

The Nail, or, as it is termed by Unna, the true nail or nail-plate, 
originates only from the floor of the nail-fold as far forward as the 
anterior edge of the lunula. As to its formation, it may, therefore, 
be imagined as springing from its matrix vertically in the form of 
an involuted, shield-shaped plate, its convexity regarding the proximal 
phalanx. It may then be viewed as pressed downward over its nail- 
bed in front, with partially unfolded edges enwrapped by the epi- 
dermis of the sides, the narrowed point of the shield, elongated when 
untrimmed, projecting at some distance beyond the tip of the finger. 

"With this conception, it is easy to understand that the nail is con- 
stituted of horny filaments, or coherent strata of cornified cells, 
passing from the matrix or floor of the nail-fold. The upper surface 
of the nail grows, therefore, from the bottom of the nail-fold ; the 
under surface from the lunula ; and the intermediate layers propor- 
tionately from the parts between. It is firmly attached to the nail- 
bed by ridges upon its under surface, which interlock with corre- 
sponding grooves on the upper face of the bed. 

The Nail-fold, crescentic in shape, clasps the nail posteriorly and 
at the sides. It is formed of connective tissue, whose bundles are 
interpenetrated by numerous coil-glands and fat-columns. The epi- 
dermis beneath the nail exhibits prickle, granular, and horny layers. 
As the nail is gradually liberated from its bed, both at the sides and 
point, the cornification of the horny layer becomes more complete, so 
that finally, as the nail-plate is pushed forward, it no longer rides 
over the cells of the rete, but over a completely cornified tissue. 

If the pulp of any nail-bearing phalanx be pressed with moderate 
force against any firm object, the naked eye can detect upon the 
surface of the nail, just behind its free border, a whitish and yellowish 
band, convex anteriorly and somewhat increasing in width laterally. 



THE NAILS. 



47 



This line, described by Unua, is also visible when no pressure is 
exerted upon the digit, its width varying under the conditions 
described. ' This border represents the space in which the three layers 
of the epidermis from the skin of the point of the finger, viz., the 
horny, the granular, and the prickle-layer, successively come in con- 
tact with the under surface of the nail. 



Fro 



— JV 




Implantation of the nail at its border. P, papilla; decreasing in size toward the middle line ; B, rete 
mucosum, which broadens toward the border of the nail, and forms irregular prolongations; R', E, 
epidermal layer ; N, plate of the nail. Magnified 500 diameters. (After Heitzmann.) 



The lunula is the relatively light-colored space extending from the 
middle part of the nail-fold posteriorly to its well-defined convex 
border in front. After artificial removal of the nail-fold, it is seen 
to extend to the posterior and enclosed border of the nail-plate. It, 
therefore, represents that part of the matrix of the nail which is not 
concealed by the nail-fold. Its color is not due to absence of vascu- 
larity, but solely to opacity of the keratoginous cells (Ranvier) 
which are concerned in the production of the horny threads that form 
the nail. 



48 GENERAL SYMPTOMATOLOGY. 



II. 

GENERAL SYMPTOMATOLOGY. 

In cutaneous, as in other diseases, the clinical signs or symptoms 
of the morbid process are those by which it is recognized alike by the 
patient and the physician. It is usual to divide these into subjective 
and objective : the former, those appreciated by the patient alone in 

consequence of his sensations ; the latter, by the eye and the touch of 
another who undertakes the investigation of the disease. It should 
be remembered, however — and this is a matter of some importance in 
this connection — that many objective signs are made manifest to the 
eye and touch of the patient himself, and liable to be interpreted or 
misinterpreted by him, with consequences which should not be 
ignored. 

Subjective Symptoms. — The purely subjective symptoms of a 
disease of the skin are those manifested to the patient by sensations 
other than those connected with vision and his own sense of touch. 
They include; sensations of itching, smarting, ting-ling, pricking, and 
burning; sensations as of increased or diminished susceptibility to 
the contact of foreign bodies; of increased or diminished tempera- 
ture ; pain in various grades of severity ; and disordered sensations, 
as of the crawling of insects over the part, currents of hot or cold 
vapors or liquids, and compression of portions of the skin by either 
cords, bands, or closely fitting plates. The character of the subjective 
sensations experienced by a patient often proves an aid to the phy- 
sician in recognizing the nature, not merely of a present disease, but 
of one also which has preceded. Thus the sensation produced by an 
attack of erysipelas is rarely an itching, while the latter is highly 
characteristic of eczema and scabies ; the pain of zoster and the ting- 
ling of urticaria being distinctly different, not only from each other, 
but from the subjective symptoms named above. 

Objective Symptoms. — The study of the objective symptoms of 
a cutaneous disease is of paramount importance. In uo respect does 
the skilled physician so distinguish himself from one who is inexpert 
as in the recognition of the typical or atypical objective characters 
presented in diseases of the skin. The study is one which can be 
neglected safely by no diagnostician, and its rewards are precious in 
every department of medical science. These symptoms are spread 
before the eye, and their legibility increases with every hour of care- 
ful attention. 

These signs of skin disease — or, more literally, skin injury — are 
called lesions, and it is usual to classify them as primary and second- 



ELEMENTAEY LESIONS. 49 

ary. Such a division is, however, open to criticism, since, viewed 
from the standpoint of time merely, some of the so-called primary 
lesions of the skin become in' turn secondary and even tertiary. Thus 
a papule which might at oue moment be called primary, may be 
transformed wholly or in part into a vesicle, which thus becomes a 
secondary lesion ; and such vesicle again, in the evolution of a dis- 
ease, may become a tertiary pustule. The latter finally may result 
in a quaternary crust. In the following pages these symptoms of 
skin disease will be distinguished as elementary and consecutive. 

Elementary Lesions. 

In describing the average size of cutaneous lesions, it is less con- 
venient to state their measurement in fractions of a line or millimetre 
than to convey an approximate idea by a comparison with familiar 
objects of relatively fixed dimensions. The objects usually selected 
for this purpose are, beginning with the smallest, the seeds of poppy, 
mustard, and rape; the coffee-bean; the pea; the bean; the cherry; 
the finger-nail ; the chestnut ; the horse-chestnut ; the egg of the hen 
and of the goose ; and the orange. To these may also be added the 
point and the head of a pin. The student will find it useful to 
familiarize himself with the size of the small seeds mentioned, that 
their names may at once suggest to him the relative size of the lesions 
to which they are compared. 

Maculae, Spots, or Stains, are generally circumscribed 
alterations in the color of the integument, differing as 
to the size, shape, hue, and duration of the dyschromia, 
and unaccompanied by elevation or depression of the 

SURFACE. 

Examples of macula? are to be found in the exanthematous rashes 
(measles) ; in localized hypersemige of the capillary plexus of the 
corium, disappearing in various degrees according to the pressure 
exerted on the part (rosacea) ; in visible acquired development of 
bloodvessels in the skin (telangiectasis) ; in congenital vascularization 
of the surface (nsevi) ; in variously colored blood extravasations and 
stases (purpura) ; in stains produced by contact with dyes (hand- 
workers in aniline) ; and in pigmentary changes such as those pro- 
duced by solar heat (freckles), or by leprosy. 

Extensive non-circumscribed changes in the skin color are seen in 
the course of several general disturbances of the economy, as in yellow 
fever, cancer, chlorosis, albinism, Addison's disease, argyria, and 
icterus. 

Spots of various color and device are also produced by the inten- 
tional or accidental introduction of pigmented particles beneath the epi- 
dermis, as by the process of tattooing, the explosion of gunpowder, etc. 

Maculae exhibit a wide variation in color from a rosy pink to a 
chocolate-brown or even a black. This difference has suggested the 
employment of such descriptive terms as roseola, erythema, and pur- 



50 GENERAL SYMPTOMATOLOGY. 

pura, which have, unfortunately, served to distinguish both features 
of diseases and diseases themselves. 

A macula which encircles another lesion, as, for example, the halo 
around the vaccine vesicle, is called an areola. Linear hemorrhagic 
streaks are called vibices; punctate and larger extravasations of blood 
are termed petechia? and ecchymoses. 

Papulje, or Papules, are solid or compressible, ephem- 
eral OR PERSISTENT, CIRCUMSCRIBED PROJECTIONS FROM THE 
SURFACE OF THE SKIN, VARYING IN SIZE FROM A POPPY-SEED 
TO A COFFEE-BEAN. 

These exceedingly common skin symptoms vary greatly in their 
shape, color, location, career, and significance. Thus they may be 
flattened at the apex, acuminate or pointed, conical, rounded, or 
depressed at the summit to form an umbilication. They may be 
pale, rosy, dark or lurid-red, purplish, or even blackish. They may 
develop in transitory or persistent processes; they may be trans- 
formed into lesions containing fluids ; may desiccate and furnish scales 
either at apex or base; may degenerate into ulcers: or enlarge into 
tubercles or tumors. They may be scratched, torn, or rubbed so 
as to lose their typical appearance ; they may come and go ; be 
sensitive to sudden changes in the blood-current, and yet be them- 
selves persistent. 

The mixed forms described above are generally named vesico-papnlar 
or papulo-vesicular, papnlo-squamous, papulo-pustular, lesions, etc. 

Lesions which simulate the papule and which, though described 
under that title, really belong to another category, are the small, 
semi-solid elevations of the surface which form at the orifices of the 
ducts of the cutaneous glands and follicles. Thus they may consist 
of little heaps of epidermis about the hair-follicles (lichen pilaris, 
keratosis pilaris), or of inspissated sebum collected in one or all of the 
acini of the sebaceous glands (milium, comedo). 

The concomitants of an eruption of papular type also vary. Thus 
there may be a febrile process, or extensive infiltration of the skin 
about and beneath the papules (prurigo) ; or itching of the most in- 
tolerable character (eczema papillosum) ; or production of trifling 
sensations of annoyance, as a slight burning without other subjective 
symptoms (acne, lichen planus). 

Papules which are transformed into moist lesions become covered 
with a crust. Papules which are scratched or torn by the finger- 
nails usually betray the fact in the minute and flat blood-scafe dried 
upon their surface. Papules which ulcerate may be followed by 
scars. Papules which have undergone the process of involution may 
be followed by macular sequelse. 

Pomphi, Urticje, or Wheals, are more or less transitory, 
rosy-red and whitish, irregularly shaped and sized eleva- 
tions of the surface of the skin, produced by blood-stasis 
in spasm of the vessels, accompanied by a tingling or 



ELEMENTARY LESIONS. 51 

PRICKING SENSATION AND CHARACTERIZED BY RAPIDITY OF EVO- 
LUTION AND FREQUENCY OF RECURRENCE. 

The typical wheal is seen in the disease known as nettle-rash 
(urticaria), where closely packed, shining, roundish and whitish, pea- 
to finger-nail-sized elevations of the skin are visible, surrounded by a 
slightly rosy border. They are firm to the touch, and arranged in 
patches, circles, bands, gyrations or striations, often disappearing in a 
brief time and recurring with or without a renewal of the cause. 
They are occasioned by a rapid exudation of serum into the rete or 
pars papillaris of the corium. This is supposed to be due to clonic 
vascular spasm, producing irregularities in the lumen of the skin 
capillaries, under the influence of the vaso-motor nerves which supply 
a small area of the superior pars vascularis of the derma. The sen- 
sations produced by the wheal are particularly stinging, burning, 
pricking, and itching. They are often surrounded by an areola. 

"Giant" wheals are such as enlarge to the dimensions of an egg 
or a tomato, or cover extensive areas of integument, as, for example, 
the entire surface of the buttock or shoulder. 

Relics of disappeared wheals are usually transitory erythematous 
macula?, but in rare cases a more or less deep pigmentation is left, 
which slowly disappears (urticaria pigmentosa). 

It should be borne in mind that at times the wheal-like condition 
is assumed by papulae, as also by lesions resulting from such trauma- 
tism as the bites of insects, reptiles, horses, dogs, etc. 

TUBERCULA, OR TUBERCLES, ARE CIRCUMSCRIBED, SOLID, GEN- 
ERALLY INCOMPRESSIBLE, AND PERSISTENT, NODOSITIES OF THE 
SKIN, VARYING IN SIZE FROM A COFFEE-BEAN TO A CHERRY. 

They may be largely projected from the free surface of the integu- 
ment, or be deeply seated in the skin, and but a small portion become 
evident to the view externally. Their varieties as to shape, color, 
size, and other features, correspond in great part to those described 
in connection with papules. They may be attached by a broad base 
to the skin, or be pedunculated, or even pendulous. Their seat is 
usually in the deeper portions of the corium or the subcutaneous 
connective tissue. Degenerating and ulcerating tubercles are followed, 
as might be supposed in view of their volume, by considerable 
destruction of tissue, and in cases of repair by correspondingly exten- 
sive cicatrices. Tubercles are seen in such diseases as fibroma, mol- 
luscum epitheliale, syphilis, leprosy, sarcoma, and cancer. 

Tubercles are often described as merely enlarged papules ; but the 
distinction between these two forms of lesion will be better recog- 
nized when attention is paid to the particular portion of the skin in 
which each takes its origin. Papules spring oftenest from the super- 
ficial layers of the derma ; tubercles, on the other hand, from the 
deeper. This being remembered, it will be clear that at times a 
tubercle may project from the surface to a less extent than a papule, 
though its larger volume is evident as soon as the skin within which 
it has developed is handled. 



52 general symptomatology. 

Phymata, Tumores, ok Tumors, are masses of solid 
tissue, or of solid tissue more or less commingled with 
fluids of variable consistency, differing ix size, shape, 
color, and in the benignity or malignity of their career, 
either located within or beneath the skin, or, being 'at- 
tached to the latter, projecting from it to a variable 

EXTENT. 

The mere fact thai a lesion of the skin approaches in dimensions 
the size of a tumor is in itself an element of gravity. Tumors may- 
originate in mere hyperplasia of the living matter; may consist of 
new formations of greater or less danger to the vicinage, or the gen- 
eral economy ; may be formed of blood or lymphatic vessels, or both 
in the same lesion; may embody large fluid-containing cysts; may 
be built up of nervous tissue, fat, bundles of connective-tissue fibres, 
glandular elements, and indeed of any of the elements which exist 
physiologically in the human integument. 

Examples of tumors are seen in fibroma, sarcoma, carcinoma, and 
rhinoscleroma. 

A^esiculje, or Vesicles, are elevations of the horny layer 
of the epidermis with limpid, lactescent, or sanguinolent 
fluid contents, varying in size from a poppy-seed to a 
coffee-bean.' 

Typical vesicles are seen in the minute and transitory lesions 
occurring in the vesicular form of eczema. They are usually filled 
with a clear serum. Variations from this type are, however, com- 
mon. Thus, they may be flattened, acuminate, roundish, umbilicated, 
or conical ; may be fully distended or partially collapsed upon their 
contents ; may have a short or long duration ; may be distended 
with milky, chylous, or a blood-stained fluid ; may be opalescent, 
yellowish, reddish, or blackish in color ; several may coalesce to form 
a many-chambered lesion; and a single one or several such may 
undergo transformation into pustules or bullse. Vesicles may termi- 
nate by accidental or spontaneous rupture, their contents freely flow- 
ing forth upon the surface of the peripheral integument ; or they 
may desiccate to a crust; or may even terminate by one of the ulcera- 
tive processes. They may or may not be accompanied by pruritus. 
Minute vesicles, which are merely the external apices of large-cham- 
bered accumulations of fluid beneath, occasionally form upon the 
surface of the skin. 

Such are seen in the course of lymphangiectasis. 

Pustul.e, or Pustules, are circumscribed cutaneous ab- 
cesses, covered with an epidermal roof-wall, and varying 
in size from a millet-seed to a filbert. 

The typical pustule contains pus, and is colored yellowish, yel- 
lowish-green, or brownish-green, according to the admixture of its 
contents with blood. The pus being an inflammatory product, it 
necessarily indicates the occurrence, at the base of the pustule, of an 



CONSECUTIVE LESIONS. 53 

inflammatory process. Pustules, like vesicles, may be roundish, 
acuminate, globoid, conical, umbilicated, surrounded by an inflamed 
or normal integument ; may be superficially or deeply seated ; may 
terminate by rupture or desiccation ; may or may not be followed by 
an ulcer and ultimate cicatrix. They may be seated either upon the 
free surface of the skin, or at an orifice of a follicle, in which case 
they represent an inflammation with purulent product in the duct or 
gland beneath. 

Pustules may originate as such ; or as a consequence of transfor- 
mation of vesicles; or after a change in a papule, which may thus 
come to have a purulent apex. According to Auspitz, they invari- 
ably originate from vesicles. Pustules often result in the formation 
of crusts, the latter varying in color according as the pustules from 
which they originated contained a clear serum or blood. 

Transitional forms between vesicles and pustules are termed vesico- 
pustules. Pustules of a large size and resting upon an indurated, 
engorged, and elevated base are often called ecthymatous. 

Pustules are seen in syphilis, variola, eczema, scabies, acne, and 
many other cutaneous diseases, including several forms of dermatitis 
medicamentosa. 

Bulkze, or Blebs, are superficial or deep-seated eleva- 
tions OF THE SKIN HAVING FLUID CONTENTS, DIFFERING IN 
COLOR, SHAPE, AND CAREER, AND VARYING IN SIZE FROM A 
COFFEE-BEAN TO A GOOSE'S EGG. 

Blebs have been described as large vesicles ; but this fails to define 
exactly their pathological character. Like vesicles they may contain 
serum, lymph, blood, or pus ; and be variously colored in the degrees 
according to which their contents become visible through a semi- 
transparent roof-wall. They may be globoid, hemispherical, oval, 
crescentic, semi-crescentic, conical, and even exhibit angles. They 
may be seated upon an apparently unaltered or evidently morbid 
integument ; and may or may not present a peripheral areola. 

Bulla? may persist or rupture ; may desiccate or degenerate into 
ulcers ; may collapse after the escape of their contents, and the roof- 
wall become glued to the base from which it was originally raised. 

Bullae usually occur in extremely debilitated states of the system, 
and are, as a rule, of graver portent than other fluid -containing, 
lesions of the skin. They occur in scalds and burns, in pemphigus, 
leprosy, erysipelas, syphilis, and moist gangrene. 

Consecutive Lesions. 

Squamae, or Scales, are attached or exfoliated epithe- 
lial LAMELLJ3, WHICH HAVE BECOME APPRECIABLE AT THE 
SURFACE AS THE RESULT OF SOME MORBID PROCESS IN THE SKIN. 

A physiological desquamation is constantly in progress over the 
superficies of the body, whose evidences are not pronounced in skins 
properly cleansed by ablution. In disease processes, however, des- 



54- GENERAL SYMPTOMATOLOGY. 

qnamatioi] may occur as a distinct symptom in various forms. Thus 
the scales may be minute, fine, branny, dirty-white, or yellowish ; 
they may be larger, pearly-white, shining; dry or fatty; aggregated 
so as to resemble flaky pie-crust ; exfoliating in extensive sheets, as 
from the entire sole of the fool or palm of the hand; or in glove- 
finger-like sheaths, as from the surface of a digit. They may be 
scanty, scarcely perceptible, and so attached as to require force for 
their removal; they may fall spontaneously in a pulverulent shower, 
being bo abundant as to iill the garments or bed-clothing of the 
patient. 

Furfuraceous desquamation is that form in which fine bran-like 
scales are shed from the surface. 

Scales occur in eczema, psoriasis, pityriasis, ichthyosis, syphilis, 
and in several of the parasitic diseases of the skin. 

It should not be forgotten that scales are frequently intermingled 
with other lesions, often they succeed the latter. Thus a papule may 
scale at its apex, or surround its base with a collarette of loosened 
epidermal plates, beneath or between which a macular stain is visible. 
Again, they may develop from the macule, the tubercle, or the tumor. 
Though generally conceded to be evidences of a dry and non-dis- 
charging disease of the skin, they are at times accompanied or suc- 
ceeded by moisture of the part affected. 

The term "scales" is sometimes applied to the flattened plates of 
dried sebum which form on the scalp and portions of the trunk in 
seborrhea sicca. 

Crust.e, or Crusts, upon the skin, are relics of the 
desiccation of its pathological products. 

Crusts never occur as primary symptoms of disease. When formed 
by the desiccation of serum only they are of a yellowish, straw- 
yellowish, or reddish-yellow hue ; when composed largely of dried 
pus they are colored greenish, or greenish-yellow ; and, when there 
has been an admixture of blood, they are usually brownish or blackish. 
At times they suggest in appearance gum, honey, or Venice turpen- 
tine ; in shape they may have the form of the concavo-convex lid of 
a watch-ease; in color and shape they may resemble the half-shell of 
the oyster, or the carapace of a small turtle. They may be delicate 
and thin ; bulky and thick ; friable or mealy ; may be firmly attached 
to the subjacent tissues, or readily separable ; may cover a sound, 
though tender and reddened epidermis ; may conceal a superficial, or 
deeji, foul-based ulcer, by whose secretions from beneath they are 
raised above the plane of the skin and increased in thickness. They 
may be circumscribed and no larger than a small finger-nail; may 
envelop an entire limb or organ, as the leg or the penis ; or, finally, 
mav be so irregularly disposed among other lesions, papules, pustules, 
excoriations, and open ulcers, that it is difficult to define their out- 
line, and even to recognize their identity. Crusts formed of dried 
sebum are greasy to the touch, dirty-yellowish in shade, and usually 
seated upon a non-infiltrated base. Crusts are common in eczema, 



CONSECUTIVE LESIONS. 55 

syphilis, leprosy, seborrhcea, and a large number of other diseases of 
the integument. 

Excoriations are superficial solutions of continuity, 
usually involving portions of the skin affected with 
prukitus, and resulting from mechanical violence. 

Excoriations, in appearance among the most trivial of skin lesions, 
possess a value from the diagnostic standpoint which can scarcely 
be overestimated. They occur as striated, linear, punctate, circular, 
or irregularly shaped, furrowed wounds, at times involving areas of 
flat surface, oozing with serum or blood, covered with dried blood or 
crusts, yellowish or reddish in hue, and for the most part both 
induced and accompanied by severe pruritus. They may coexist with 
hyperemia and infiltration of the skin beneath, brought on by the 
irritative character of the continuous, or, more frequently, interrupted 
cause by which they were begotten. 

Excoriations become significant according as they indicate scratch- 
ing, tearing, or other species of wounding by the finger-nails, and 
rubbing portions of the integument with foreign bodies. In the 
former case they are significantly recognized in those portions of the 
body most accessible to the hands, though in the case of eczematous 
children and infants they may originate by the rubbing together of 
the knees ; or the leg of one side by the feet and toes of the other. 
The loss of tissue may extend deeper than the rete — at times invading 
the papillse of the corium, which bleed in consequence. 

Excoriations may occur without the appearance of other lesions, as 
in the disease called pruritus ; but where itching is severe and induced 
by a cutaneous exauthem, the lesions constituting the latter may be 
intermingled with, obscured, or even obliterated by excoriations and 
the pathological processes to which they give origin. Thus macules, 
vesicles, pustules, and papules may undergo change ; and the recog- 
nition of the type of the existing disease be correspondingly difficult. 
Excoriations are common in skins wounded by lice, bed-bugs, and 
gnats ; in the subjects of eczema, scabies, intertrigo, and prurigo ; and 
in individuals with special sensitiveness of the integument to the 
action of a medicament employed either internally or externally. 

Rhagades, or Fissures, are linear solutions of con- 
tinuity, USUALLY OCCURRING IN PREVIOUSLY INFILTRATED 
PORTIONS OF THE SKIN. 

They may extend to the derma, and even invade yet deeper 
structures; may be painful, or the reverse; dry, secretory, or in- 
crusted ; are often hemorrhagic, and usually formed with sharply cut 
walls. They are of frequent occurrence in the vicinity of the articu- 
lations, in which situations they are induced or • aggravated by the 
joint-movement stretching or tearing tissues whose extensibility has 
been diminished by any morbid process. Fissures may terminate in 
ulceration. They vary as to length, curve, and tenderness. They 
are often exquisitely painful, and greatly complicate the skin disease 



5b GENERAL SYMPTOMATOLOGY. 

in which they occur. They may follow the curve traced by the 
boundaries of bodily organs near which they occur — as, for example, 
the line of the posterior junction of the ear with the heat], or of the 
breast of a woman with the thoracic wall where it rests. Fissures 
occur iu eczema, syphilis, dermatitis, and lichen ruber. 

Ulcera, or Ulcers, are losses of substance resulting 
prom a previous pathological process involving the 
corium, and, ix cases, the subcutaneous tissue. 

Cutaneous ulcers differ greatly in size, shape, color, edges, base, 
career, and, indeed, in all their characteristics. Every ulcer has an 
outline, base, floor, edges, and secretion. The outline may be cir- 
cular, crescentic, reniform, ovoid, serpiginous, or with horseshoe-like 
contour. The base, or underlying tissue, may be .-oft, supple, indu- 
rated, or in a state of active inflammation, with consequent infiltration. 
The floor may be glazed, shallow, deep, excavated, cup- or funnel- 
shaped, " worm-eaten," crateriform, sloughy, covered with a tenacious 
or readily removed secretion, granular, puriform, or hemorrhagic. 
The edges may be clean-cut, having a punched appearance, under- 
mined, everted, ragged, regular, or contracting, with a whitish inner 
border of advancing cicatrization. The secretion may be scanty, 
limpid, puriform, profuse, ichorous, and odorless or exhaling an 
offensive stench. They may be so crust-covered as to be invisible, or 
so exposed and erosive in action as to render the affected surface in 
the highest degree unsightly. They may be acute or chronic, insen- 
sitive or productive of intense pain ; may heal by cicatrization, remain 
open for a lifetime, or prove fatal by either destruction of parts 
essential to life, or by exhaustion of the vital forces. 

Cicatrices, or Scars, are new formed substitutes fop lost 
connective tissue. 

Scars never succeed excoriations, fissures, or other solutions of 
continuity in the skin, which have not penetrated as far as the derma, 
and resulted in destruction of a portion of the elements of which the 
latter is built up. They possess the highest importance for the 
diagnostician, since they point invariably to a pathological process 
whose career is terminated, the characteristic features of which they 
frequently embody They may be regarded as the special and per- 
sistent imprints upon the integument, of the serious disorders from 
which it has suffered. 

To a certain extent, as already shown, scars retain traces of the 
special peculiarities of the lesions, and even of the diseases, which 
they suc-eed. The identification, however, of the individual prede- 
cessor in each instance is, in the present state of our knowledge, not 
always possible from a study of cicatrices alone. The extent of 
knowledge in this direction is, however, rapidly increasing; and in 
many cases the certainty thus acquired is of incalculable value to the 
diagnostician. 

Scars are remarkable for their tendency to contraction and gradual 



GENERAL SYMPTOMATOLOGY. 57 

decoloration. They may be minute, punctate, extensive in area, 
attached to underlying tissues, depressed, raised above the plane of 
the peripheral skin, seamed with furrows, pliable and soft, indurated, 
traversed by ridges, knotted, and as irregular in contour as the ulcers 
already described. They may extend in digital, linear, or annular 
prolongations 'toward contiguous portions of the skin, and by subse- 
quent contraction induce considerable distortion and deformity. Thus 
they may drag down an eyelid, and ectropion ensue ; may glue the 
lobe of the ear to the cheek ; may evert lip or nostril. When recent, 
they are usually reddish in tint ; when older, be pigmented in centre 
or circumference ; or, as is common, exhibit a gradual decoloration, 
centrifugal in its progress. They may be the seat of pain from an 
entrapped nerve- filament; may reopen to ulceration ; or be accom- 
panied by no subjective sensation. Not rarely they become the origin 
of the disease known as cicatricial keloid. Scars are unprovided 
with hairs, papillae, or the orifices of sweat-pores and sebaceous gland 
ducts. As implied in the definition given above, scars may result 
from any disease or injury of the skin which involves loss of connec- 
tive-tissue elements in the corium. 

To these lesions Bazin adds, as elementary forms, the mucous patch 
of syphilis ; the cuniculus, or furrow, produced in the skin by the 
acarus scabiei ; and the sulphur-colored crusts of favus. These, 
however, are not general, but special features of individual disorders, 
and are best studied in connection with the latter. 

The elementary lesions of the skin are termed by Auspitz, " anthe- 
mata;" groups of such lesions, "synanthemata;" and, as in accord- 
ance with common usage, generalized eruptions affecting the entire 
surface of the body, " exanthemata." The word "erythanthema" is 
used by this writer to describe groups composed of several of the 
elementary lesions of the skin, as, for example, of papules, vesicles, 
and pustules rising from a common, reddened, and hypersemic base. 

In addition to the names of the lesions of the skin just enumerated, 
certain peculiarities of cutaneous symptoms are described in qualifying 
terms, which here require definition. They relate chiefly to the color,, 
shape, distribution, and method or period of evolution of lesions as 
they are observed in individual cases. The more important of these 
terms, as used by modern writers, are arranged below, alphabetically, 
with a brief explanation appended to each. A much larger list of 
obsolete adjectives, employed by older authors, is purposely omitted. 

Abdominalis. Located on the abdominal surface. 
Acquisitus. Acquired. 
Acuminatus. Having a pointed apex. 
Actjtus. Of acute course. 
Adttltorum. Occurring in adult years. 
iEsTiVALis. Occurring in the season of summer. 
Aggregatus. Collected in patches. 
Agritts. Acute, or angry in appearance. 
Albidus. Of whitish color. 
Angiectaticijs. Vascularized. 



58 GENERAL SYMPTOMATOLOGY. 

Annularis, [n the form of a ring. 

Axsn.ATrs. In the form of a ring. 

Apyreticus. Unaccompanied by lever. 

Areatus. ( Iccurring in areas. 

AetIFICIALIS. Producible artificially. 

ASYMMETKICALIS. ( >f different distribution on the two lateral halves of the 
body. 

Autumnalis. Occurring in the fall of the year. 

BRACHIALIS. Occurring on the surface of the arm. 

Cachecticorum. Occurring in debilitated subjects. 

Capitis. Occurring on the head, usually the seal]). 

Caverxosus. Large chambered. 

ChronICUS. Chronic in course. 

ClRCINATUS. Of circular outline. 

Circumscriptum. Having a definite contour. 

Coxfertus. Arranged in close proximity, with coalescence of lesions. 

Confluens. Arranged in close proximity, with coalescence of lesions. 

Contagiosus. Capable of communication by contagion. 

Corporis. Occurring on the surface of the body ; employed usually to 
designate an eruption upon the trunk, as distinguished from that on the 
head or extremities. 

Crustosus. Crusted. 

( IrystALLINUS. Of crystalline appearance. 

DlFFUSUS. Irregularly disposed. 

DlSCRETUS. Having isolated lesions. 

Disseminatus. Disseminate, without regularity of distribution. 

Eruption. Is used of the totality of all patches and lesions upon the person 
of one individual. 

Erythematosus. Having a reddish blush. 

Essextialis. Idiopathic. 

Exfoliativus. Having a tendency to exfoliation or shedding from the 
surface of the body. 

Exulceraxs. Is employed by French writers to designate superficial 
ulcerations, or lesions with a tendency to such a process. By English and 
American authors it is sometimes used to designate unusually deep ulcera- 
tions. 

Facialis. Located on the face, usually as distinguished from the scalp. 

Favosa. Displaying crusts of favus. 

Febrilis. Accompanied by a febrile process. 

Femoralis. Occurring on the surface of the thigh. 

Fibrosus. Composed of fibrous tissue. 

Figuratus. Having a figured appearance. 

Flavescexs. Of yellowish hue. 

Foliaceus. Resembling a leaf or leaves. 

Follicularis. Concerning the cutaneous follicles. 

Fuxgoides. Resembling a fungus. 

Furfuraceus. Exhibiting numerous, fine, bran-like scales. 

Guttatus. Of the size of a drop of water. 

Gyratus. Having a serpiginous or gyrate outline. This is usually the 
result of a coalescence of imperfect circles or semicircles. 

Herpetiformis. Vesicular or herpetic in type. 

HlEMALIS. Occurring in the winter season. 

Humidus. Accompanied by moisture. 

Hypertrophicus. Characterized by hypertrophy. 

Hystrix. Having lesions projected or erected like quills. 

Imbricatus. With crusts or scales overlaid like tiles. 

iMPETKil nodes. Pustular. 

Infantilis. Occurring in infancy. 

IXTERTIXCTUs. Distinguished by color. 

Iris. ( >ccurring in more or less distinctly defined concentric rings. 

Labialis. Occurring upon the surface of the lip. 



GENERAL SYMPTOMATOLOGY. 59 

Lenticulaeis. Of the size of a small bean. 

Lividus. Deeply colored. 

Maculosus. Discolored. 

Madidans. Characterized by moisture. 

Marginatus. Having a denned margin. 

Medicamentosus. Produced by external or (more commonly) internal 

medication. 
Melanodes. Of blackish color. 
Miliaris. Of the size of a millet seed. 
Mitis. Of mild, benignant type — the reverse of agrius. 
Multiformis. Exhibiting simultaneously several types of elementary 

lesions. 
Neonatorum. Occurring in the newborn. 
Neuriticus. Having nervous association. 
Nigricans. Of black or blackish color. 

Nodosus. With development of nodes or tuberosities of the surface. 
Nummularis. Of the size of small coins. 
Oleosus. Accompanied by an oily secretion. 
Palmaris. Occurring on the palms. 

Parasitarius. Produced by an animal or vegetable parasite. 
Parasiticus. Produced by an animal or vegetable parasite. 
Patch. The aggregation of several isolated or confluent lesions. 
Phlegmonosus. Accompanied by deep-seated inflammation. 
Phlyct^enoides. Characterized by groups of small vesicles. 
Pigmentosus. Accompanied by pigmentation. 
Pilaris. Belated to the hair. 
Plantaris. Situated on the soles of the feet. 
Planus. Flat. 

Polymorphous. This is the Greek equivalent of the Latin multiform. 
Pr^eputialis. Situated upon the prepuce. 

Progenitalis. Situated on the exposed mucous surfaces of the genitalia. 
Pruriginosus. Accompanied by itching. 
Pubis. Located upon the skin or hairs of the pubes. 
Punctatus. Occurring in dots or points. 
Ehagadiformis. Fissured, or tending to produce fissures. 
Rosaceus. Having a rosy or pinkish hue. 
Euber. Red, usually dark red in color. 
Scutiformis. Having the shape of a shield. 
Sebaceus. Concerning the sebaceous glands or their secretion. 
Senilis. Occuring in advanced years. 

Serpiginosus. Literally, creeping — advancing in irregular gyrations. 
Siccus. Dry, unaccompanied by moisture. 

Solitarius. Having an isolated lesion, or with isolated lesions. 
Symmetricalis. Similarly distributed on the two lateral halves of the body. 
Toxicus. Poisonous. 

Uniformis. Exhibiting lesions all of one type. 
Universalis. Affecting the entire surface of the body. 
Urticatus. Accompanied by wheals. 
Uterinus. With association of uterine disorder. 
Variegatus. Exhibiting several distinct colors. 
Vasculosus. Accompanied by vascular development. 
Vernalis. Occurring chiefly in the spring of the year. 
Versicolor. Exhibiting several shades of the same color. 
Vulgaris. Of the usual or commonly observed type. 



60 GENERAL ETIOLOGY. 



III. 

GENERAL ETIOLOGY. 



Toe study of the causes of diseases of the skin gives us a glimpse 
of the etiology of diseases in general. In the lowest representatives 
of life, the greatest dangers to existence originate in exposure to 
assault from other and stronger representatives in search of their 
prey, in other terms an external danger. In man, the highest repre- 
sentative of the animal scale, the perils of existence are complicated 
by his social necessities and his artificial methods. He can never, 
however, at any period of his existence, divest himself from the 
necessity of exposure to external peril. The plan of his organs 
and the play of his normal activities are perfect, even to the recoverv 
from all but mortal injury and repair of moderate loss The 
struggle for existence of the ideal man is intended to be with that 
which is without; his body meanwhile furnishing him with a com- 
fortable tenement and a fair fortress. In the purview of nature 
there should be no internal revolt. When such occurs, it is usually 
the result of his ignorance, his folly, or his vice. 

Viewed in this light, the causes of the diseases of his skin will be 
seen to differ but little from those which induce disease in his other 
organs. Exposed to cold, he suffers from a pneumonia; to injury, 
a fracture or a dislocation ; to the contact of poisons, he vomits or 
purges ; to contagion from his fellow-man, he has the cholera or 
plague ; all these are capable of producing diseases of his skin. But 
meantime his organs have a tender care for themselves and each 
other, compared with which the solicitude of a mother for her child 
becomes insignificant. The stomach refuses to digest itself; the 
lung, unwounded, admits no air to the pleura ; the bladder, so long 
as it is unruptured by violence, permits no drop of urine to pass 
into the peritoneal sac. In the same proportion, and under the 
same general law, do the viscera refuse to generate a poison which 
will injure the integument ; and the fluids of the body, a vicious 
"humor" which will damage the bones. 

Reasoning thus from analogy alone, it will be seen that the preva- 
lent doctrines respecting blood-poisons of internal origin must be 
greatly restricted. Eczema alone, in its manifold forms, furnishes 
more than one-half of all the diseases of the skin ; and yet every 
one of these several forms can be produced at will and artificially 
upon the integument of man. 

Again, it is not to be forgotten that the body is really invested 
with a continuous skin which not only is extended over its outer 
surface, but is also reflected so as to line all passages by which it is 
traversed within. This inner investment, called the mucous mem- 



GENEKAL ETIOLOGY. 61 

brane, is as truly a part of the skin as the epidermis and corium of 
the face or hand. This is clear : first, as shown from the facts of 
evolution, because representative animals of the lower scale are 
found capable of complete inversion, by which the outer skin 
becomes the inner or digestive, and the inner, in turn, the outer or 
protective organ; second, as shown by histology, the anatomical 
characters of the skin and mucous membrane being similar ; third, 
as shown by pathology, the extroverted mucous membrane rapidly 
undergoing the transformation which causes it to resemble the skin; 
while the inverted skin, as when the thighs are by disease kept in 
continuous contact and moistened, assumes the characteristic features 
■of mucous membranes. In the study of cutaneous etiology, it is 
manifestly proper to regard as of external origin all causes which 
operate from without upon either the outer or the inner skin of the 
body. 

This much premised, it can be said that the large proportion of all 
diseases of the integument originate either from the action of solar 
heat and light; temperature changes at the surface of the body; 
contact with various fluid and solid substances with the production 
•of either factional, traumatic, or toxic effects ; or the development 
upon and within the skin, of vegetable parasites. It remains merely 
to consider these causes somewhat in detail, remembering that at 
times several influences cooperate in the production of a given 
effect. 

The action of solar light upon the skin is usually coincident with 
the operation of another mode of motion called heat. To the former 
are to be attributed the production of freckles, " tan," and other 
pigmentations of the surface; to the latter, the erythema, eczema, 
and, various grades of dermatitis which may follow exposure to the 
direct rays of the sun. Other temperature effects, including those 
produced by extremes of both heat and cold, are to be classed in the 
same category. According to Hebra, exposure of the skin to a 
temperature over 100° Fahrenheit, produces merely a transient 
erythema, which under a further elevation of 65° F. will not subside 
for several days. At a temperature of 212° F., all grades of acute 
dermatitis are awakened with the production of bullae, up to the point 
where complete destruction of the integument occurs. 

The influence of the seasons is of the same general character. 
Some cutaneous diseases are worse in summer; others in winter. 
Prickly heat (lichen tropicus) is peculiar to certain warm seasons ; 
frost-bite and its subsequent hyperemia, exudation, or gangrene, 
occur in winter; pruritus is common in cold weather; erythema mul- 
tiforme is most frequent in the autumn and the spring. 

The questions originating when considering the influence of 
climate, are so complex that they are differentiated with difficulty. 
They involve the study of soil, potable water, diet, atmospheric 
humidity and temperature, and the sociological conditions of a 
given locality. Pellagra is said to originate in certain coun- 
tries from the diet of the people. The severe forms of ringworm 



62 GENERAL ETIOLOGY. 

observed in India result probably from exuberance of vegetation in 
the parasite under the influence of heat and moisture The aggra- 
vated species of scabies seen in Norway is doubtless the product of 
filth and eold, with the itch-mite as an exciting cause. It must, 

however, be admitted that the more extensive the study of diseases 
claimed to be peculiar i<> given degrees of latitude and longitude, the 
less they are found to depart from the types recognized in other 
countries. 

Frietional effects are perceptible in the action upon the skin, of 
the clothing. Coarse flannel is known to exeite pruritus, especially 
when aided by profuse sweat and the muscular movements of the 
laborer. Trusses, corsets, napkins, "pads," supporters, crutches, 
orthopaedic apparatus, hat-bands, stockings, garters, and a long list 
of similar articles, are responsible for many disorders, especially when 
soiled with physiological or pathological secretions. So in the occu- 
pation of men, bakers, masons, confectioners, blacksmiths, tailors, 
and an equally long list of laborers and tradesmen suffer from the 
results of friction, to which is often added the influence of trauma- 
tism or the action of chemical irritants. 

Traumatism plays a most important part in cutaneous etiology. 
It includes the action in scratching of the nails, the knees, heels, 
elbows, etc., well illustrated in the case of infants whose hands are 
confined, as well as the influence of several articles used for the same 
purpose — pieces of cloth of various kinds, etc. In this way excoria- 
tions, and even infiltrations of the skin, are induced. Under the 
head of traumatism should be considered also injuries of the surface 
produced by animals, occasionally with the added effect of a toxicant. 
Here are included the wounds produced by lice, fleas, bugs, and 
acari ; the bites of serpents, horses, dogs, and cats; and the accidents 
producing traumatism of every kind, not omitting the intentional 
wounds inflicted by the surgeon and their results. 

Toxicants operate upon the surface with and without the produc- 
tion of traumatism. Thus the worker in dyes and the wearer of 
the dyed garment manufactured, may suffer alike; while vaccination, 
when it produces a generalized exanthem, operates first in the wound 
made by the lancet of the vaccinator. Medicaments used upon the 
outer skin, such as mercury, croton oil, iodine, antimony, and nitrate 
of silver, are capable of engendering disease ; and those which, being 
swallowed, operate as irritants to the inner skin or mucous mem- 
brane, may have a similar effect. Others being swallowed and sub- 
sequently absorbed from the gastrointestinal tract, produce a toxic 
effect upon the skin in the effort to eliminate them. Thus the 
bromide and iodide of potassium, quinine, arsenic, copaiba, and 
many other articles of the materia mediea, occasion erythematous, 
vesicular, pustular, and bullous rashes of variable persistence and 
different external characteristics. 

To the class of toxicants must be added the articles of food and 
drink, which under ordinary circumstances, and perhaps to the 
majority of individuals, serve to nourish the body, but yet operate 



GENERAL ETIOLOGY. 68 

as poisons to the few. Thus alcoholic drinks, shell-fish, preserved 
meats, certain fruits, cheese, pickles, and many other dietary articles, 
are known to originate or aggravate pruritus, urticaria, eczema, and 
acne. Cracked wheat, Graham bread, oatmeal, and buckwheat have 
been found, in certain susceptible individuals, to induce pruritus, 
urticaria, and occasionally decided roughness of the skin. It should 
be remembered in this connection that any undigested or indigesti- 
ble article of food may excite similar effects at one time and not at 
another, in the same individual, the resulting difference being due to 
the varying condition of the alimentary canal. 

An important list of toxicants is furnished by the poisons either 
of animal origin or requiring for the mature development of their 
germs, culture in animal fluids or tissues. All of these are external 
sources of disease. None is known to be generated de novo in the 
human body. To this class belong the exanthematous fevers, 
glanders, farcy, malignant pustule, and syphilis. Some require trau- 
matism for their introduction into the system ; some do not, and 
some are capable of introduction both with and without traumatism. 

This class includes the cutaneous disorders due to the presence of 
bacteria. In the present state of pathological science, it is impossible 
to define accurately the etiological import u nee of the microbes which 
have been demonstrated to exist in a number of diseases of the skin. 
In some, for example, lepra, these bacteria may be recognized as effi- 
cient factors of the disease ; in others, as, for example, lupus vulgaris 
and syphilis, the etiological value of the bacilli which have been 
recognized in tissues affected with these diseases cannot to-day be 
irrefutably demonstrated. 

Some cutaneous diseases are produced by the growth of the vege- 
table parasites upon and within the skin and hairs, and in the folli- 
cles. To this class belong ringworm of the scalp, beard, and skin ; 
tinea versicolor, and favus. 

Of the causes of diseases named, it may be said that no one of 
them is necessarily productive of such effects. The majority of men 
and women expose themselves daily to the action of light and heat, 
are subjected to friction, suffer from wounds of the integument, and 
come in contact with toxic agents, without exhibiting a disease of the 
skin. Often there is a marked degree of sensitiveness of the integu- 
ment peculiar to the individuals who suffer, which may exhibit itself 
in several members of one family, or exist in one person for but a 
brief period of time. Again, an individual idiosyncrasy may be 
exhibited, in consequence of which an article, harmless to all others, 
becomes to one person only a source of serious discomfort. 

The various physiological changes of the human body are never 
the causes of diseases of the skin, but at times furnish special oppor- 
tunities for the operation of such causes. Thus in the rapid tissue 
evolution of early life, eczema and lupus are relatively common — 
carcinoma and tinea versicolor rare. At puberty the hairs of the 
beard of the male are liable to the incursions of the trichophyton ; 
and the nipple and breast of the woman become the seat of eczema 



<3-± GENERAL ETIOLOGY. 

from epiphora of milk. The <>1<1 man and the old woman may be- 
come the victim.- of cancel-, aggravated forms of pruritus, and horny 
growths. Dentition, menstruation, pregnancy, and the menopause 
disturb the physiological equilibrium, and at times render the access 
of other disturbing forces exceptionally facile. The sexual appetite 
leads t<> excesses which bear fruit in attacks of herpes, pruritus, and 
syphilis. And the unceasing excretion from the skin surface, with 
constant deposit thereof effete material, may, when there is prolonged 
disregard of the laws of cleanliness, induce a liability to disease of the 
skin, which is especially marked in the case of infants and children. 

The power to transmit skin disease by heredity is of less impor- 
tance than is generally supposed. It is most conspicuous in the in- 
stances of hereditary syphilis; but even here the transmission of the 
disease is not without singular exceptions, and is limited to certain 
periods of the disease in the progenitors. The transmitted disease is 
also most common in the foetus, which is in direct communication 
with the mother, and rapidly diminishes in frequency with every 
month of separate existence, till late and very late instances of hered- 
itary syphilis have come to be received with suspicion. Many of the 
examples cited of hereditary transmission of cutaneous diseases are, 
without doubt, cases of coincidence, which, considering the number 
of patients affected annually with eczema and psoriasis for example, 
should not be regarded as of very rare occurrence. 

The list of causes recognized as directly productive of diseases of 
the skin are, without question, under special circumstances, capable 
of operating as indirect etiological factors. Temperature changes, 
contacts with the external world in all harmful degrees, and toxicants 
are prime agents in the production of diseases of internal organs; and 
these, in turn, may induce changes in the skin, of the nature of disease. 
The uterus, the stomach, the liver, the kidney, the heart, the nervous 
centres, and the intestinal tract may become disordered, and the result 
be declared not only in disturbance of the function of these organs, 
but in an attack of urticaria, pruritus, jaundice, or erythema. 

Without attempting to decide whether the preponderance of evi- 
dence is in favor of internal or external causes as productive of the 
greater number of cutaneous maladies, it is certain that disorders of 
the digestive tract sustain to many of them a most important relation. 
Thus the several conditions included under the somewhat indefinite 
term "dyspepsia," habitual constipation due to torpor of the intestinal 
tract, a portal circulation impeded by functional disturbance of the 
liver, and many other affections of the alimentary canal may each be 
productive of cutaneous accidents or complicate the results of the 
latter. In the same proportion, diseases of the kidneys, suprarenal 
capsules, spleen, anc] generative organs of both sexes may induce or 
be complicated by diseases of the skin. 

The influence of the nervous system, when considered in this con- 
nection, may be either directly or indirectly exerted. There is scarcely 
any efflorescence upon the surface of the integument, the arrangement 
of whose lesion is not in part determined by the nervous fibres whether 



GENERAL ETIOLOGY. 65 

with or without the intervention of an effect upon the bloodvessels. 
Both vaso-niotor and trophic nerve-fibres are capable of inducing 
skin changes either after direct lesion or stimulation of the nervous 
centres, or through the medium of the latter after peripheral acci- 
dents of the same kind. Passive congestions of the surface, leading 
to oedema and violaceous blush of the skin, often result from circu- 
latory changes; and, in fine, any constitutional disease, by impairing 
general nutrition, arresting repair, hastening waste, or in other direc- 
tions impoverishing the protoplasm of the body, is capable of inducing 
disorder in the skin as in other organs. Thus in cancer, chlorosis, 
ansemia, and cholera there are significant alterations in the hue of 
the integument which not merely possess a diagnostic value for the 
clinician, but attest the sympathetic unity of each organ of the body 
with all others. 

There are authors who affirm, with eminent French dermatologists, 
that certain states or diatheses explain the origin of many cutaneous 
maladies. These diatheses, whether termed " arthritic," " dartrous," 
u lithsemic/' or "herpetic," cannot be demonstrated as efficient causes 
for the production of the diseases attributed to them. The chief ex- 
ponents of these opinions are not agreed among themselves as to the 
names of such supposed systemic conditions, nor as to the symptoms 
by which they are betrayed, nor as to the exact method of combating 
their effects. The claim that these states are of a nature analogous 
to the tuberculous or syphilitic diathesis, is to-day well nigh deprived 
of foundation, since the bacterial origin of tuberculosis and syphilis 
is at least on the road to demonstration. The complexus of symptoms 
characterized by evolution without demonstrable cause, by frequency 
of recurrence, by obstinacy under treatment, and by alternation of 
cutaneous with other maladies, is no proof of a diathesis, but rather 
of the failure of science to appreciate perfectly all the several condi- 
tions which produce the result. As to the group of phenomena well 
described by Dr. Da Costa 1 as characteristic of lithsemia, even with 
the fullest recognition of such conditions the cutaneous symptoms 
displayed by those who are the subjects of that state are neither con- 
stant, uniform, nor peculiar. While no wise physician would hesi- 
tate to treat patients for the relief of such states when there was coin- 
cidence of skin disease, he would not be, therefore, justified, even 
after coincident relief of the entire group of symptoms of disease, 
in attributing one part of this group to a constant association with 
the others in the case of all patients. 

Without attempting fully to discuss or to settle these questions, it 
is necessary to establish the fact that the eruptive phenomena in any 
skin are produced by a multitude of ever-shifting and varying com- 
binations of causes. Even the syphilodermata are influenced from 
hour to hour by drugs swallowed, by external irritants, and by con- 
ditions of the general health, such as a transitory diarrhoea, or a fit 
of coughing. In the light of our present knowledge, it is the part 

1 The Nervous Symptoms of Lithasrnia. American Journal of the Medical Sciences, p. 313, 1881. 

5 



66 GENERAL DIAGNOSIS. 

of the physician, on the one hand, to neglect consideration of no effi- 
cient factor in the origin <>r evolution of a cutaneous disorder; and, 
on the other hand, to refuse to assign to a diathetic state only a group 
of* symptoms which may occur in persons where no such systemic 
condition can account for the evidences of disease. 



IV. 
(xEXERAL DIAGNOSIS. 

The establishment of an accurate diagnosis in cutaneous diseases is 
essential to their successful management. This statement is rendered 
necessary in this connection by the prevalence of a belief among the 
uneducated that the disorders of the skin, exhibited for the most part 
in visible symptoms, can be safely treated on general principles, 
without a recognition of the nature of the malady. By many prac- 
titioners the demand for an accurate diagnosis is ignored in conse- 
quence of a too general impression that the desired end is to be 
pursued through great and perplexing obscurity. Yet with patience, 
method, a habit of careful observation (without which no physician 
is successful), and a reasonable degree of skill, both the practitioner 
and student can, in the large proportion of all cases, attain their 
purpose. 

It is a popular error that the sole requisite for establishing a diag- 
nosis is the exhibition of the affected portion of the integument to 
the eve of him who is consulted with a view to its relief. The phy- 
sician is supposed to inspect this surface attentively for a few moments, 
and then to pronounce definitely upon the nature of the disease 
present, and the therapeutic measures to be adopted. But far more 
than this is requisite, and, indeed, fully as essential here as in the 
investigation of disease involving any other organ of the body. 

It is first necessary to secure a history of the physical and mental 
condition of the patient in the past ; then should follow the special 
history of the disorders of the skin ; lastly, an examination of the 
affected integument. For the purpose of methodically arriving at 
these facts, and of preserving them for future reference, they should 
be systematically recorded. The following are some of the points 
upon which it will generally be found useful to secure information : 

The name, residence, age, sex, occupation, and married or unmarried 
state of the patient should be known, as also, whenever practicable, 
the health-history of parents and children. In the case of women it 
is not only necessary to learn the history of the menstrual function in 



GENERAL DIAGNOSIS. 67 

the past, but of the highest importance to be informed as to the 
previous occurrence of abortions and miscarriages, and, if such have 
occurred, the order observed by these with relation to the birth of 
viable infants. The significance and value of several of these facts 
have been described in the chapter on etiology. ' With respect to the 
history of the products of conception, it should never be forgotten that 
these have a most important bearing upon the question of syphilitic 
infection; and the absolute exclusion of syphilis in any obscure case 
is a long step in the direction of an accurate diagnosis. In the case 
of male patients, questions will usually elicit either admission or 
denial of the fact of a precedent or present venereal disease, and the 
answers should be regarded as valueless or trustworthy according as 
they are or are not substantiated by corroborative clinical facts. 

Then should follow some record of the habits of the patient, as to 
active or sedentary employment, bathing, food, and drink, including 
under the latter term the use of beer, wine, and spirits. The history 
of any previous disorders, whether of the skin or other organs, should 
be satisfactorily clear ; and, with respect to the latter, the dates of 
occurrence, recurrence, and convalescence be at least approximately 
discovered. The patient should also make known whether he has 
had refreshing sleep ; whether he has undergone mental anxieties 
(domestic, financial, etc.) ; whether he has suffered in his digestive, 
respiratory, circulatory, genito-urinary, or nervous system. 

This much ascertained, the patient should be encouraged to narrate 
as succinctly as possible, and as far as may be in his own terms, the 
history of the present cutaneous disorder. He should give the sub- 
jective sensations it has produced, as also the objective features 
presented to his own vision and touch. In the case of infants this 
information will, of course, have to be obtained from the mother or 
nurse. The treatment to which the disease has been subjected should 
then be detailed. This frequently furnishes a key alike to the diag- 
nosis and therapy of the disorder. In an incredibly large proportion 
of all cases, ignorantly directed and vicious internal or external medi- 
cation has either begotten or aggravated the disease of the skin. 
This much ascertained, the physician is ready to examine the affected 
surface for himself. 

During, however, the verbal interrogations which are required for 
this part of the exploration of the case, the watchful and observant 
practitioner will probably have secured for himself some useful 
-information of which the patient is totally unconscious. Much of 
this is difficult to describe, as it is the rich fruit of a wide experience 
and careful scrutiny. "With a gentle, courteous, and sympathizing 
manner, the diagnostician must combine the art of a detective and the 
skill of a swordsman. Glancing occasionally at the face of his 
patient while making record of the answers given, he will, of course, 
have observed any eruption upon that portion of the body. He will 
have made a mental note of the temperament of the sufferer, or any 
movement made by the latter indicating a tendency to scratch or rub 
any portion of the skin. He will have noticed the posture, clothing, 



68 GENERAL DIAGNOSIS. 

and head apparel ; the* existence of hair on the scalp or extensive 
baldness ; the condition of the exposed hands, as indicating manual 
labor or the reverse; and. in the absence of facial lesions, will have 
observed the general tint of the skin of the face, as indicating 
anaemia, chlorosis, or a general condition of cachexia. The facial 
expression, as indicative of anxiety or placidity, habits of debauch, 
sexual excesses, etc., will not have escaped his attention. All this 
and much more will have possibly enabled the questioner to direct his 
interrogatories into the channel where they would elicit the most 
useful responses. The posture, cries, facial expression, and general 
condition of nutrition of the infant will have been no less carefully 
noted. 

Proceeding to the examination of the affected integument, the phy- 
sician must assure himself of a good light, as colors are best distiu- 
guished by daylight, and artificial illumination should be reserved 
for exploration of the cavities of the body. The air of the apart- 
ment should be sufficiently warm to permit of exposure of the pers< >n 
without discomfort. Adult males and children of both sexes should 
have the clothing completely removed, so that all portions of the skin 
may be inspected. One portion of the body may, however, be exam- 
ined, and then recovered, if desired, while the examiner proceeds to 
direct his attention to another. In the case of women the investi- 
gation should be conducted with all the tact and delicacy to which 
the sex is entitled. 

The examination, whenever practicable, should extend over the 
entire surface of the integument. The importance of this point can 
scarcely be exaggerated. It must be remembered that the physician 
should be very much wiser than his patient, and the assurances of 
the latter are always to be accepted with reserve. Thus, one who 
exposes his leg merely, stating that this is the only part of his body 
affected, may have concealed beneath his clothing extensive vari- 
cosities of the veins of the thigh, a typical syphilitic exanthem over 
the belly, a significant scar on his elbow, an extensive patch of tinea 
versicolor on the surface of the chest, or a blennorrhagic discharge 
from the urethra, the medication of which has induced the rash for 
which he seeks relief. These are uot the rare, but the common cases 
of a daily experience. 

Observation should be had at this time of the general and special 
features of the eruption. As to the former, the following consider- 
ations should be borne in mind : 

A symmetrical eruption, one equally distributed over the two 
lateral halves of the body, is rarely the result of an etiological factor 
operating upon the outer skin. It more often points to an efficient 
cause of; so-called internal origin, one influencing the inner skin or 
the internal organs. An eruption affecting the covered integument, 
never creeping out upon the exposed surfaces, suggests the operation 
of the clothing ; as the latter may chance to prove the nidus or pro- 
tector of a parasite, the fabric which has been colored by a noxious 
dye, the recipient of a chemically altered secretion, which has proved 



GENERAL DIAGNOSIS. 69 

irritating to the surface, the instrument of friction, or the source of 
increased temperature at the surface by its non-conductivity of heat 
and unseasonable thickness. An eruption, accompanied by excoria- 
tions and scratch-lines, is that usually most severe in the parts most 
accessible to the hands, and least developed where the latter have the 
least play, as over some parts of the back. An eruption limited to 
the hands is likely to be one induced by an agent to which the hands 
alone have been exposed, as those originating in the trades and 
domestic occupations ; while in the latter, an eruption more distinct 
on the right hand, and especially about the right thumb and index 
finger, tells its own story when the hand-worker is not ambidextrous 
or left-handed. Artificially and intentionally produced eruptions, as 
in malingering, hysteria, mental depravity and insanity, usually occur 
also in parts to which the right hand finds easy access. 

Eruptions occurring on the face, hands, and genitalia of men, or 
face, hands, and mammae of women, point to external contact or 
contagion (poison-ivy, scabies, crotou-oil, etc.) ; since, next to the face, 
the hands are more commonly brought in contact with the parts named 
in the sexes respectively, as the wearing apparel of each suggests. 

An eruption, limited to the forehead, suggests an inspection of the 
hat-band, the veil, or the overlying false hair ; to the ears of women, 
a glimpse at possibly cheap ear-rings ; to the centre of the root of 
the neck, before or behind, a scrutiny of the collar-buttons and 
collars ; to the anus of the baby, an inquiry as to the changing of 
its napkins ; to the wrists of the adult, a question as to the cuffs 
worn ; to the feet, information respecting gaiters, varicose veins, 
recently cut corns, and ill-fitting shoes. Eruptions springing from 
each of these causes have been long and vainly treated as "diseases 
of the blood." 

Eruptions markedly asymmetrical are indicative of asymmetrically 
operating causes — that is, the accidents of environment, or else influ- 
ences exerted within the- body unequally on its two lateral halves. 
Thus an orthopsedic apparatus, worn to correct talipes, excites an 
eczema in the leg only of the affected side; and zoster of the trunk is 
evident on that side supplied by the intercostal nerve which has been 
inflamed. The greater stress may be laid on this peculiarity, as the 
law of symmetry, in eruptions not occasioned by causes operating on 
the outer skin, is faithfully observed in nature. The earlier syphil- 
ides, the quinine exanthem, rubeola, and even lupus erythematosus, 
are remarkable illustrations of this fact. 

Proceeding next to the special visible characteristics of the erup- 
tion, the physician will not fail to note an acuteness or chronicity of 
lesions; their color, size, distribution, tendency to become aggregated 
in patches, or the reverse; and the evidence presented as to change 
in type, the sequence or coexistence of several lesions at the same 
time — that is, the multiformity (polymorphism) or uniformity of the 
eruption. He will observe whether the limit of the affected skin is 
well defined against that which is normal, or scarcely to be outlined 



70 GENEKAL DIAGNOSIS. 

■with ;i pen or pencil. He will rapture a bleb, pustule, or vesicle, 
should such be found, to discover the nature of its contents. He will 
remove one <>r several crusts in sight, to expose the surface on which 
they rest. He will remove a few scales with the dermal curette for 
a similar reason. He will as carefully inspect the skin where the 
disease has existed, as that where it does exist. He will pinch up 
between his thumb and finger a portion of each, in order to deter- 
mine its infiltrated condition; its atrophy; or its attachment to the 
tissues beneath. He will pass his hands over the surface to recognize 
the firmness or softness of the lesions, their dryness or moisture, and 
the existence of sebaceous or perspiratory secretion. He will look at 
the mouths of the follicles, where such secretion is retained or abun- 
dantly exuded. He will discover any lice or ova on the hair; any 
ascarides at play about the anus; any unnatural formation of the 
nail, or deformity of its matrix. He will examine for inguinal, post- 
cervical, axillary, and epitrochlear adenopathy, and will thus be often 
greatly aided in his task. This done, he will question in turn for 
himself, and by the methods recognized in medical science, the organs 
of the body other than the skin. He will inspect the tongue care- 
fully, and then, if he is through with the mouth, he will be guilty of 
great error. The gums rarely deceive the questioning eye; the inside 
of the lips, fauces, and tonsils are all to be searched. A mucous patch 
here will often echo the story of a palmar or plantar syphiloderrn. 
The laryngoscope may be called for in syphilis, cancer, lupus, and 
leprosy. The degree of distention of the belly and the region of 
hepatic dulness should not be overlooked. The genitalia of men, 
and of children and infants, can usually be explored. For women 
unaffected with syphilis or disease limited to these parts, an exception 
in this particular should usually be made. 

With the necessary reserve of all very obscure cases, it may be said 
that the physician who has conscientiously conducted an examination 
after the manner described above, is in possession of the diagnosis 
for which he seeks. If the facts thus acquired have been properly 
recorded, and yet do not spell out such a diagnosis to his eyes, they 
are probably legible to others with a wider experience or riper judg- 
ment, to whom such a record is shown. It is not. claimed that this 
exhaustive method of examination is requisite in every case, as, for 
example, in order to recognize an acne or to differentiate erysipelas 
from erythema. But it is certain that few obscure cases of skin dis- 
ease will remain such under severe scrutiny, and the establishment of 
a thorough and exhaustive method of examination is important in 
the earliest experience with disease. Let the student or practitioner 
conduct such an examination in the first few cases of eruption upon 
the -ui'face of the body for which his advice is sought, and he will 
establish a habit of observation in comparison with which his pecu- 
niary or professional success in the management of the same cases 
will be indeed of trivial worth. 

Upon one special point should the inexperienced physician be 
guarded. It relates to the acceptance of a diagnosis which is not 



GENERAL PROGNOSIS. 71 

based upon such au examination as that given in outline above. A 
diagnosis by a patient is usually faulty, and the verdict of even skilled 
practitioners may be founded upon an error. The careful diagnos- 
tician should commence his task iu a spirit of scepticism, and pro- 
nounce definitely only upon ascertained facts. The man who says he 
has an "eczema" may be louse-bitten ; the woman who has been "over- 
heated" may prove syphilitic. The patient recognized as suffering 
from ringworm of the beard may not have been infected under the 
hands of the barber. Finally, the eruptions upon patients unmistak- 
ably syphilitic, are often of other than syphilitic origin. They are 
men, women, and children exposed daily to the accidents from which 
the non-infected suffer. They exhibit acne, physiological alopecia, 
and dermatitis medicamentosa equally with those who have not 
sinned sexually. 

The microscope is an instrument whose aid in establishing a diag- 
nosis of cutaneous disease can rarely be dispensed with. The con- 
tributions it has made to the knowledge had on the subject of path- 
ology are of inestimable value; and as a means of diagnosis it can 
be used with advantage both at the time of the first examination of 
a patient, and afterward for the more leisurely examination of hairs, 
scales, crusts, or portions of tissue. Those unable to secure the cost- 
lier and elaborate instruments sold by the makers, should take pains 
to provide themselves with a fairly good student's stand, and a fifth 
and half inch objective for use in the diagnosis of skin diseases. 

The diagnosis of special diseases of the skin is described in the 
chapter devoted to each. 



Y. 
GENERAL PROGNOSIS. 

The prognosis of most diseases of the human body is formulated 
with a view to the decision of the serious question of life or death. 
Occasionally this question arises in connection with skin diseases. 
Many of the latter are trivial ; some are grave ; a few, inevitably fatal 
in their termination. Thus general exfoliative dermatitis, leprosy, 
sarcoma, carcinoma, at times lichen ruber, and variola in the unpro- 
tected, are of grave portent; while the ordinary congestions and exu- 
dations, the great majority of all cases of acquired syphilis in adults, 
and the entirely curable diseases induced by parasites do not excite 
alarm in the breast of the average patient with respect to his longevity. 

The questions, however, as to his future, which are urgently pressed 
by the victim of cutaneous disease, are both numerous and important. 



72 GENERAL PROGNOSIS. 

He is anxious as to the time during which he must .suffer; as to the 
possibility of conveying his disease to his progeny or other members of 
his family ; as to the disfigurement of his person which might result; 
as to the scars which he may have to carry for the remainder of his 
life; as to the possible recurrences of his malady in the future. The 
responses to these questions will be largely influenced by the prog- 
nosis of the physician. 

Some diseases of the skin are acute, rapidly pursue their course, 
and are then prompt to disappear. Others are chronic, rebellious to 
treatment of the most energetic and skilful character. Others, again, 
though not shortening life, are never relieved while life is coutiuued. 
Some disappear, only to reappear at more or less regular intervals. 
There arc cutaneous diseases which affect oue individual but once in 
his lifetime; others which reappear at the instant the patient is again 
exposed to their exciting cause. There are cutaneous diseases so dis- 
torting and destructive in their effects, that their victims have com- 
mitted suicide under the influence of the morbid emotions which they 
have as a consequence experienced. 

The mental distress occasioned by even an insignificant cutaneous 
disorder is often out of all proportion to its excitiug cause; and this 
should always be regarded in establishing a prognosis. The sexual 
hypochondriac has been made insane by an acne; and the man or 
woman affected with syphilis has been made wretched for years by a 
recurrent erythema. 

Again, a disease of the skin may coexist with grave lesions of in- 
ternal organs, and the prognosis of the disease of the one be greatly 
influenced by that demanded by the other. Thus there is occasional 
coexistence of syphilis and phthisis. Pruritus may be associated with 
Bright's disease of the kidneys; and the eczema of an infant starving 
for want of breast-milk may hasten its marasmus to a fatal termination. 

Upon the answers given to his patient inquiring as to the prog- 
nosis of the disease of the latter, will largely depend the professional 
success of the physician. Scrupulous honesty should be here welded 
with all the skill that science can command. That a disease does not 
endanger life, is not an argument in favor of its amenability to treat- 
ment. The practitioner should never suffer himself to be pushed by 
his patient to the position that an obstinate disease is readily manage- 
able. It is the height of folly to estimate lightly that zoster of the 
forehead, the scars of which the patient w r ill exhibit to all who after- 
ward look upon his face both in life and death. He who engages to 
relieve an alopecia areata in the month, may have a year in which to 
repent his precipitancy. There is no way in which the conscientious 
physician can so readily secure the confidence of his patient, and with 
it that willingness to submit to appropriate treatment, which is be- 
gotten of such confidence, as by demonstrating his ability to forecast 
the future of a disease; in other words, to describe accurately its 
prognosis. 



GENERAL THERAPEUTICS. 73 



YI. 

GENERAL THERAPEUTICS. 

A consideration of the subject of the methods of treating skin 
diseases in general, suggests at once the intimate relation which sub- 
sists between the integument and other organs of the body. The 
etiology of one, largely explains the causes of the disorders in all. 
The pathological processes in each are subordinated to the same 
general laws. The principles of treatment are very similar, in all 
the disorders of the body. 

The object to be attained by treating a cutaneous disease is, first, 
its complete relief; second, where the latter is impossible, such a 
management of the morbid process as will mitigate its severity and 
render the victim of the disease more comfortable. A higher aud 
more scientific achievement than either is the prophylaxis by which 
man is enabled to escape the disease altogether. He can by his wis- 
dom largely diminish the danger to which his integument is exposed. 
He can, to a certain extent, shelter himself from extremes of tem- 
perature, traumatism, toxic agents, and the contagious diseases. He 
can, by observing the simple rules of hygiene, fortify his skin against 
the lesser evils which may befall it. If it be true that "the people 
perish for the want of knowledge," it is certain that once in posses- 
sion of it, they can greatly enhance their comfort and prolong exist- 
ence. Here, however, the subject under consideration involves dis- 
ease which is actually present and in progress. 

Like all other diseases of the body, those of the skin may be divided 
into three classes with relatively fixed limits. 

The first embraces all the diseases which have a natural tendency 
to pursue their course to a favorable termination. It embraces all 
those affections which, either mild or severe, require absolutely no 
treatment of an active character. It is the duty of the skilful phy- 
sician to watch the evolution of these maladies, and to discharge a 
most important part by refraining from all therapeutic measures 
which in such cases might prove hurtful. By his judicious counsel 
also, he hinders patients and their friends from pursuing a course 
which might prove prejudicial to the disease. 

The second class embraces all those affections of the skin which 
are either inevitably fatal or hopelessly remediless while life is pro- 
longed. Fortunately, this includes but a small proportion of the large 
list. Here the duty of the physician is plain. He should assuage 
pain, attempt to relieve deformity, administer to the comfort of the 
afflicted in other ways, and, by his patient courage, inspire confidence 
and hope. It must not be forgotten that the skill of man has not 



74 GENERAL THERAPEUTICS. 

yet reached the acme of human need. In the presence of many 
diseases of the body, he stands absolutely helpless; and the speediest 
way to success in such cases is to begin by an honest admission of the 
plain fact. 

The third class of affections naturally embraces all not included in 
the other two. Here disease may be prolonged or shortened in its 
course, rendered acute or chronic, made more or less endurable, per- 
mitted to Income inveterate, or be absolutely relieved, by prompt and 
energetic measures, according- as it is, or is not, judiciously and skil- 
fully managed. Here are gained the most brilliant successes of the 
dermatologist; here also occur his most humiliating failures. 

In the presence of a cutaneous disease which requires treatment, 
a question naturally arises as to whether this treatment shall be in- 
ternal, that is, by medicaments ingested; or external, that is, by local 
therapeusis; or by combination of the two methods at the same time. 

With regard to the first question (concerning the Internal treat- 
ment of skin affections), which is one of pressing importance, it can 
be safely said that there are no remedies to be given by the mouth 
which can be described as certainly and specifically curative of the 
diseases of the skin. The number of medicinal agents employed 
with this end in view is incredibly large, by far the greater part 
being obtained from the vegetable kingdom. With few exceptions, 
for the most part enumerated below, the most esteemed of these exert 
only an indirect therapeutical effect upon the integument. The 
larger number of medicaments thus used are, it must be admitted, 
without value of any kind, but will probably continue to be 
vaunted as possessing specific virtues so long as credulity on the one 
hand, and avarice on the other, move the mass of mankind. 

Arsenic has long stood at the head of the list of remedies as 
valuable, when ingested, for the relief of cutaneous disorders. It is 
known to exert its effects almost exclusively upon the epithelia of 
the skin, and upon these, so far as therapeutic effects are concerned, 
only when they are in indolent conditions of subacute and chronic 
exudation. It is known to exert an unfavorable influence upon the 
epidermis when the latter is in a condition of active inflammation. 
Operating in this limited class of cases favorably, it also operates 
slowly, requiring months for the production of its curative effects. 
Its administration is at all times attended with the hazard of pro- 
ducing toxic effects, which, however, when the result of the exhibi- 
tion of the drug in medicinal doses, are usually limited to a mild 
exanthem upon the skin, moderate coryza, and some redness from 
congestion of the vessels in the eyes and eyelids. 

It is used chiefly in psoriasis, acne, squamous eczema, pemphigus, 
and lichen ruber; its dosage in cases of children being relatively large. 
It should be invariably administered only after eating, and a mini- 
mum dose be first employed in order to test the susceptibility of the 
patient to its action. It should be remembered that the toxic effect 
of this, as also of several of the other drugs mentioned below, is 
often speedily noticed after the first exhibition of a relatively small 



GENERAL THERAPEUTICS. . 75 

dose. Toleration ouce established, the dosage may be cautiously 
increased. 

The forms in which it is usually administered are the prepara- 
tions of arsenious acid, such as the liquor potassii arsenitis (Fowler's 
solution) ; the liquor arsenici et hydragyri iodidi (Donovan's solu- 
tion) ; the liquor arsenici chloridi ; and the Asiatic pill. Duhring's 
modification of this pill is obtained by making two grains (0.13) of 
arsenious acid, and thirty-two grains (2.2) each of black pepper and 
liquorice powder, into thirty-two pills by the aid of a sufficient 
quantity of mucilage. Arsenic is also at times advantageously com- 
bined with other indicated medicinal substances, such as iron and the 
iodide of potassium. 

In the first edition of this treatise, it was stated that an unpreju- 
diced view of its action, even in cases properly selected for its in- 
ternal administration, would justify the conclusion that arsenic is in 
diseases of the skin a remedy of uncertain effect, and, in that 
proportion, disappointing. Subsequent investigation, made particu- 
larly by American observers, has more than established this position. 
Dr. G. H. Fox, of New York, 1 after collation of the experience of 
a number of experts in this country concluded that the common 
practice of giving, arsenic in many cutaneous diseases was both 
harmful and irrational, not merely because of its effect in inducing 
cutaneous congestion and pruritus, but because of the reliance placed 
upou it to the exclusion of other and better methods of treatment ; 
and that the beneficial effects supposed to follow its administration 
were often due to other causes. He also called attention to the 
striking fact that no series of carefully recorded cases had ever been 
published in which notable therapeutical results had been shown to 
result solely from its administration. 

These conclusions elicited a number of statements from well- 
known physicians having experience in the management of cutaneous 
diseases, who, for the most part, assented to Dr. Fox's conclusions. 
Even in pemphigus, psoriasis, chronic eczema, and lichen ruber, 
where the remedy has been thought to possess special efficacy, it has 
in cases conspicuously failed. 

It is safest to conclude, first, that arsenic, instead of being one of the 
earliest, should be one of the last remedies selected in the management 
of cutaneous diseases by the general practitioner ; second, that, when 
thus selected, its value will probably prove greatest if the eruptive 
lesion be superficially seated, generalized, diffused, or iu evident 
association with neurotic symptoms; third, that in any case its failure 
should not be regarded as definite, if only Fowler's solution has been 
administered. 

The value of Mercury in the syphilodermata is incontestable, and 
its injudicious employment in many cases springs from that precise 
fact. The vulgar prejudice that many disorders of the skin, really 
not syphilitic, are obscure manifestations of lues iu a preceding gen- 

1 Journal of Cutaneous and Venereal Diseases. June, 1886, p. 179. 



76 GENERAL THERAPEUTICS. 

eration, and amenable to mercurial treatment, is a striking illustra- 
tion of the uecessity of accurate diagnosis in cutaneous diseases. 
Few non-syphilitic affections are benefited by continuous courses of 
mercury, though the value of the metal as an alterative in this 
small proportion of cases must be admitted. The corrosive sub- 
limate is often superseded, in consequence of its irritative effects, 
by the compounds of the metal with iodine. The gray powder is 
useful chiefly in case of infants and children, though its not infre- 
quent development of the corrosive chloride has largely limited its 
favor with Americans. Calomel and the mercurial pill should be 
employed only for transient effect, as, when administered for long 
periods, they are much more apt to produce ptyalism than the other 
preparations mentioned. 

Iodine and its compounds are also chiefly used by the dermatolo- 
gist in syphilitic disorders of the skin, but they possess a wider 
range of value than the mercurials in the treatment of other 
cutaneous affections. Here, too, the abuse of the drug furnishes a 
long list of cutaneous disorders either originated or aggravated by 
its employment. As in the use of arsenic, toleration should be 
established before large doses are exhibited. The compounds chiefly 
used are the iodides of potassium, sodium, lithium, and ammonium, 
and iodoform. It has been administered for the relief of the scrofulo- 
dermata, lupus, keloid, and syphilitic affections of the skin. As to 
the latter it may be added that in the earlier symptoms of lues it 
is often a source of positive injury. 

Cod-liver Oil is a remedy of special value in diseases of the skin, 
and was for that reason held in high favor by the distinguished 
Hebra, though its action is almost exclusively that of a nutrient of 
the general system. It is employed chiefly for its roborant effects, 
and these are similar to those of the digestible aliments. Its 
special value in the treatment of infants and children affected with 
cutaneous diseases cannot be questioned. It is, however, of great 
use also in maturer years, and is advantageously exhibited in eczema, 
lupus, scrofula, syphilis, scleroderma, and in all the disorders of the 
integument accompanied by wasting. 

Quinine, administered both as a tonic and antiperiodic, is largely 
employed in cutaneous medicine for its generally recognized systemic 
effects. It produces, in certain susceptible individuals, a peculiar 
smoothness and softness of the skin, which usually disappear when 
the drug is suspended. Like arsenic and iodine, it is occasionally 
the cause of a generalized exanthem, and is capable of producing 
other toxic effects, such as failure of the heart's action, dizziness, and 
tinnitus aurium, symptoms recognized under the designation of cin- 
chonism. It will, of course, exhibit its happiest effects in malarial 
affections with coincidence of cutaneous symptoms in the forms of 
disease of the skin associated with a neurosis. 



GENERAL THERAPEUTICS. 77 

Ergot, whether by exerting an effect upon the muscle-bundles or 
vessels of the derma, or upon the uterus, or yet by its influence upon 
the general economy, is thought to possess some value in the treat- 
ment of several cutaneous diseases occurring in both sexes. Such are 
acne, purpura, and a few other disorders. 

Calx Sulphurata may be regarded as the most efficient of the 
sulphur compounds for internal use in cutaueous diseases. Its recog- 
nized value in furunculosis has led to its employment also in 
eczema, acne, and impetigo. It is given in doses of from one-tenth 
(0.004) to one-fourth (0.016) of a grain, three or four times daily. 
Chrysarobin has been administered internally by Stocquart 1 and 
others in doses of one-sixth (0.01) of a grain for a number of 
cutaneous disorders. Ichthyol, mentioned later as of some value 
when externally employed, has also been given by the mouth. 
Jaborandi and Pilocarpine, probably as the result of the free dia- 
phoresis which they excite, have unquestionably exerted immediate 
therapeutical effects in a number of cutaneous disorders. 

Tar, Carbolic Acid, and Phosphorus are remedies which have 
been employed internally with appreciable effect in certain cutaneous 
maladies, but the action of each is uncertain, and at times highly preju- 
dicial. They have been used with advantage in cases of lupus, 
eczema, psoriasis, and pruritus ; but their internal administration has 
been to a great degree a bar to their general employment. The 
" perles" of phosphorus, and the elegant elixirs of the same drug now 
in the market, seem to have obviated this difficulty in the instance of 
at least one of these articles. 

Unpromising as is confessedly this brief review of the remedial 
influence which internal medicaments are capable of directly exerting 
upon the skin, it must not be forgotten that, while the treatment of 
the patient and the treatment of the patient's skin are practically one, 
there is some distinction to be drawn between them. No one would 
claim that castor oil, for example, possessed any efficacy in the frac- 
ture of a femur, yet such a cathartic is frequently ordered by the 
surgeon, with the happiest effect upon the condition of his patient in 
a splint. Such precisely is the inestimable value of a j>roperly con _ 
ducted internal medication in cases of cutaneous disease. 

The consideration of this point introduces us at once and properly 
to the broad field of general medicine. He is totally unfit to treat 
cutaneous diseases who is not qualified by education and experience 
for the general practice of medicine. The internal treatment of the 
patient suffering from a disease of the skin, is that which is in each 
case indicated by his general condition. Thus the aperients, cathar- 
tics, diuretics, and occasionally even the anodynes, are demanded, 
and, when judiciously employed, accomplish beneficial results. Few 

1 Ann. de Derm, et de Syph. 1884. 



78 GENERAL THERAPEUTICS. 

practitioners can afford to dispense with the use of the preparations 

of iron, for example, iu cases of ana?mia. Even the patient affected 
with a parasitic disease may ncrtl one of the bitter tonics, and the 
youth with vegetations upon the glans may require first to be rid of 
his blennorrhagia. 

Among the medicinal substances indicated by the general condition 
of the patient affected with a disease of the skin yet not directly 
acting upon that organ, none are more useful than the diuretics, 
cathartics, and remedies acting as stimulants to the secretions of the 
chylopoetic viscera. At this day no educated physician believes in 
employing medicines with a view to either the so-called "driving 
out" or " driving in" of a disease of the skin, much less to a use of 
evacuants with a view to carrying off a supposititious materies morbi. 
The remedies suggested above are undoubtedly, for the most part, 
useful in diminishing the congestion of the cutaneous capillaries, an 
important point not only with respect to the comfort of the patient 
but to the relief of his ailment. 

He who accomplishes the largest success will not, finally, neglect 
consideration of the diet, hygiene, and social surroundings of the 
patient. The chief value of many of the mineral springs and health 
resorts of this country lies in the change of the manner of living 
which they invite and necessitate. Sunshine, pure air, recreation 
after the care and toil of business, change of climate, of foods and 
drinks, and even of cooks, often decide the question of speedy 
recovery. Unfortunately, both in this country and abroad, many of 
the health resorts are peopled by unscrupulous charlatans, with a 
myopic tendency to attribute all the benefits to be derived from these 
sources to the medicinal virtues of this or that particular spring, 
aided always by treatment according to their own peculiar methods. 
Many patients affected with disease of the skin are thus made worse 
by a temporary residence at noted health resorts, and, therefore, it is 
often the case that a visit to the seashore, the mountains, or any 
healthful place in the country proves conducive to far greater prac- 
tical results. 

This understood, it is admitted that many of the springs of our own 
country possess a therapeutical value in cutaneous diseases actually 
dependent upon the constituents of their waters. A new study of 
this interesting and important subject is demanded by the annual 
discovery of new sources within the borders of the United States, 
which give a large promise for the future. Many of those ignorantly 
recommended as valuable for the entire list of cutaneous disorders 
are either entitled to no such encomium or maybe usefully employed 
only in a limited number of skin affections. Large successes are 
undoubtedly to be credited to the scores of ferruginous, sulphuretted, 
chlorinated, alkaline, arsenical, purgative, and other springs whose 
names appear in the lists given by European writers on this subject. 
Most of these are represented in this country by waters of equal, if 
not greater value, furnished by the numerous spas of Michigan, Vir- 
ginia, New York, Colorado, New Mexico, Utah, and other States and 



GENERAL THERAPEUTICS. 79 

Territories of the Union. As these are brought within reach of a 
larger portion of the population of the country by greater railway 
facilities, their medicinal value will be better appreciated, and they 
will be much more systematically employed than at present. They 
offer a most promising future for the internal treatment of diseases of 
the skin in this country. 



In the External treatment of diseases of the skin, the indications 
are, to hasten repair when this is possible ; to alleviate distress, if 
palliatives only are admissible ; to destroy absolutely or excise the 
diseased tissue, when this is justifiable. The following are the prin- 
cipal substances employed as external applications : 

Water, either pure or medicated by holding other substances in 
solution or mechanical suspension, is applied either in baths or 
lotions. Baths, local or general, may be employed for days contin- 
uously, or but for a few moments at a time. They are given with 
water of varying temperature, cold, warm, or hot. Cold baths of 
short duration are generally followed by a sharp reaction, the skin 
becoming congested after the normal temperature of the surface is 
regained. Thus it is that cold sponging of the inflamed skin is 
usually grateful so long as it is continued ; and is succeeded after- 
ward by an aggravation of the symptoms which it was intended to 
relieve. Continued applications of cold water are not open to this 
objection. 

Hot baths are followed by a more or less enduring relaxation of 
the integument, while those given with tepid water are chiefly 
macerative of the surface. It should be remembered that the appli- 
cation of watery lotions to the broken surface of the skin, is liable to- 
be followed by endosmosis, unless the specific gravity of the serum 
of the blood and that of the fluid of the bath or lotion are nearly the 
same. This imbibition of fluids by the broken skin is accompanied 
by slight swelling of the tissues and productive of disagreeable 
sensations. 

The most perfect of all methods by which water is applied to the 
surface of the body, is that which most resembles the water-bath in 
which the tender skin of the foetus is safely immersed for consecutive 
months. Here the bath is continuous ; the temperature, that of the 
viscera of the living animal ; and the delicate skin of the unborn 
child, anointed with a fatty substance which actually interferes with 
the macerative action of the surrounding fluid so long as vitality is 
preserved at the average standard. The comfort and therapeutic 
value of a bath prepared and administered in approximation to this 
ideal, can scarcely be overestimated. Were it not for the difficulties 
with which it is attended, so far as relates to many portions of the 
surface of the body, it would be possible with this single therapeutic 
measure to rob the exudative affections of the skin of a great part of 
their formidable features. 

In acute inflammations of the skin, the application of pure water, 



3"> GENERAL THERAPEUTICS. 

even when of proper temperature, is often prejudicial to the integu- 
ment ; and soap and water washings may prove quite harmful. The 
greatest caution must be exercised in giving instruction to patients as 
to the washing of the inflamed skin. 

Water for external application, as in the bath, is medicated by the 
addition of a large number of substances, such as marine salt, sodic 
and potassie salts, alum, tannin, the mineral acids, mucilages, gelatin, 
bran, and, especially in the Southern States of this country, the 
orange leaf. 

The alkaline bath, made by adding the bicarbonate or the biborate 
of sodium to water of the proper temperature in the proportion of 
twelve ounces of either salt to thirty gallons, is usually grateful to 
the inflamed skin. Sulphur baths are best prepared by adding an 
ounce of Vleminckx's solution 1 to the same quantity of water. 

When employed as a lotion, water is made to produce a sedative 
effect by the addition, of opium, belladonna, glycerine, carbolic acid, 
hydrocyanic acid, zinc, bismuth, mercury, lead, and the alkaline 
bicarbonates with the sodic biborate. It is rendered stimulating by 
the admixture of alcohol, most of the acids and alkalies in stronger 
solution than in the soothing or sedative lotions; and by a large 
number of substances which operate upon the surface either mechani- 
cally or chemically. It is also rendered astringent when tannin, lead, 
and similar medicaments are dissolved in it ; and by its union in 
various degrees with soaps and alkalies a solvent effect is produced, 
either upon the cuticle itself or upon pathological or foreign products 
upon its surface. 

Water is employed also, both in the form of the douche and vapor 
bath. When evaporation is prevented, by covering the wet surface 
of the body with an impermeable tissue, such as gutta-percha or 
rubber cloth, still further macerative effect is produced. The sweat 
alone is in the same way converted into a macerating agent. 

Lotions other than those containing water are often serviceable. 
The fluid in such case may be alcoholic, ethereal, or oleaginous, and 
medicated to any desired effect. 

S< »aps are of great value wheu applied to the skin. The hard, or 
soda, soaps are employed chiefly for the purposes of ablution. The 
soft, or potash, soap has a wider therapeutic range. In consequence 
of the small excess of caustic potash which it contains, it not only 
serves to cleanse the skin of any accumulations upon its surface, 
native or foreign, but also to exert a mild, destructive effect upon the 
horny layer of the epidermis. Digested with rectified spirits of wine 
in the proportion of two parts of the soap to one of the alcohol, it 
forms the well-known " spiritus saponis kalinus " of Hebra, a prepa- 
ration which the modern dermatologist employs constantly with 
admirable results. 

1 The formula is : 

~fy. Calcis, Sss; 1G 

Sulphur sublim. gj; 32 

Aq. dest. 3x ; 32o| M. 

Coque ad 3vj ("200] deinde ultra. 
Sig. " Vleminckx's Solution." 



GENERAL THERAPEUTICS. 81 

Medicated Soaps, containing carbolic acid, glycerine, tar, sulphur, 
and various oils, are sold in the shops, but contain so small a portion 
of the individual medicament from which each is named, that they 
are practically worthless except for purposes of ablution. The author 
has had such prepared under cold pressure, so as to contain medicinal 
substances in therapeutic proportions ; but, after experimentation, has 
concluded that other forms of administration are preferable. 

Fatty and Oily Substances are applied to the skin either 
directly by pouring, or by friction, or by the mediation of compresses, 
bandages, etc., which are saturated or spread with the material to be 
applied. The oils may be used for either nutritive, soothing, or 
stimulating effects. To the first and second classes belong cod-liver, 
lard, olive, almond, linseed, neat's-foot, castor, and similar oils ; to 
the third class, the oil of tar, of cade, of white birch, of the cashew 
nut, and of juniper. 

Fatty substances are also applied in the form of ointments or 
pomades. They are compounded with various medicinal substances, 
according to the requirements of each case, such as the salts of mer- 
cury, zinc, copper, lead, and sulphur ; pyrogallol, chrysarobin, carbolic 
and hyposulphurous acids; tar, camphor, iodoform, balsam of Peru, 
hydrate of chloral, the extracts of opium, belladonna, etc. 

The products of petroleum refinement, known as Vaseline and 
Cosmollne, though not true fats, are increasingly employed for similar 
purposes, and continue to enjoy high favor in this country and abroad. 
They are particularly useful as bases for ointments for application to 
the hairy portions of the body, such as the scalp, when more con- 
sistent salves paste the hairs to the surface in an unsightly mass. 

Glycerine — even the best — is, when applied in its purity to the 
skin, usually irritating. It is, however, exceedingly useful when 
diluted or made a component part of lotions and ointments. When 
combined with starch it makes, in different proportions, a series of 
combinations known as glyceroles, or glycerolates. These are pasty, 
semi-solid substances which are capable of varied medication, as in 
the glycerole of the subacetate of lead proposed by Dr. B. Squire, of 
London. They are useful chiefly as protectives of the surface. 
Glycerine, when used in a fluid soap, is an exceedingly valuable agent 
when a milder effect is desired than that produced by the spirit of 
soap described above. The Vienna preparation known as Sarg's 
fluid soap is an admirable substitute of this sort when a soft shampoo 
is required for the scalp. 

The Pastes employed for local application in diseases of the skin 
have been greatly perfected by Lassar and Unna. 1 

These pastes are valuable especially in the exudative affections, 
where salves are often either not well tolerated or actually prove 
irritating to the skin. The pastes, when applied to such surfaces, 
form a protective and adhesive dressing, which may be medicated as 
desired. 

1 Monatsh. f. prakt. Derm., February and March, 1884. 
6 



82 GENERAL THERAPEUTICS. 

They are prepared with kaolin [terra alba, or Armenian bole of 
red color, when it is desirable to have the application resemble the 
color of the skin], gum, lead, dextrine, glycerine, and other substances. 
Formula' for each are here appended : 

Kaolin in a pure state, with ecpial parts of vaseline or glycerine, or 
with almond, olive, or linseed oil, in the proportion of two to one, is 
readily applied in a thin layer over the skin. When it is desired to 
add the oxide of zinc, or the plumbic acetate, the kaolin and oil or 
glycerine are first carefully mixed, in order to prevent the formation 
of an insoluble compound — e. g., It. Kaolini pur., ol. lini [vel 
glycerini], aa 30 parts; zinci oxidi, liq. plumb, subacetat., aa 20. M. 

For making lead pastes, litharge is boiled with twice the quantity 
of vinegar till the latter has evaporated and a damp but drying paste 
is left, which may be, on occasion, remoistened with a small quantity 
of vinegar — e. g., I^j. Lithargyr. subt. pulv. 50 ; aceti, 80. Coque 
usque ad consistent, pastas : deinde adde ol. lini [v. glycerini, v. ol. 
olivse], 10. M. 

In the two forms of pastes above described, the adhesive and 
desiccative qualities are obtained from the main ingredients, but in 
those resulting from combinations of gum, starch, and dextrine, 
these results are for the most part obtained by the addition of other 
ingredients, such as sulphur, zinc, etc. A good basis, semi-solid, 
rapidly drying, and fixing its ingredients well upon the surface, is the 
following: ly. Amyli oryzae, 3; glycerini, 2; aq. dest. 15. M. 
Coque ad remanent. 15. For convenience, the solid substances are 
mixed at once with the glycerine, starch, and water, and then heated 
together. Tfy. Zinci oxid. 50 ; acid, salicylic. 2 ; amyli oryzae, 
glycerini, aa 15; aq. dest, 75. Coque ad 140. For a sulphur paste : 
!ty. Sulphur, prsscipit. 40 ; calc. carb. 2 ; zinc. oxid. 20 ; amyl. 
oryzae, 15; glycerini, 20; aq. dest. 75. Coque ad 120. 

Here is a formula giving a combination of starch and lead re- 
sembling cream : ly. Amyli oryzae, 10; glycerin. 30; lithargyr. 30; 
acet. 60. Evapora ad 80. By adding 10 parts more of litharge, and 
20 more of vinegar, and evaporating to 90, a thicker and cement-like 
paste is formed. 

To make use of dextrine, the officinal pulverized article is selected, 
and a simple paste of this forms a good drying base. An added half- 
weight of glycerine is required if powders are also combined with the 
paste — e. g., Iy. Zinc. oxid. 40 ; dextrin., aq. dest., aa 20 ; glycerin. 40 ; 
sulphur, sublim. [vel. sod. sulpho-ichthyol.] 2. Cpq. A mixture of 
dextrine and lead is thus prepared : 1^. Lithargyr. 30 ; acet. 50. 
Coque ad remanent, 50; adde dextrin., aq., glycerin., aa 15. Coque. 
If too consistent, these pastes are made to spread easily by the addi- 
tion of a few drops of hot water. Such water is not required in 
making the paste if another fluid be one of the constituents, as, I^i. 
Dextrin., glycerin., liq. plumb, subacet,, aa 10. M, Coq. ft. pasta. 

For the gum pastes, gum arabic is used in the proportion of one 
part of mucilage and glycerine to two of the powder selected, mixed 
without heat— c. g., jfy. Zinc. oxid. 40; hydrarg. oxid. rub. 2; 



GENERAL THERAPEUTICS. 83 

mncilag. acac., glycerin., aa 20. M. 1^. Cret. prseparat., sulphur, 
subliru., aa 2 ; picis liquid. 8 ; amyli, 20 ; mucilag. acac, glycerin., 
aa 15. M. 1^. Acid, salicylic, 20 ; glycerin. 20; mucilag. acac. 30; 
ol. ricini, 10. M. 

The author gives the following details respecting the availability 
of these pastes for different ingredients : Lead is best used as an 
acetate, either in a simple paste or with dextrine; the carbonate, 
oleate, and iodide combining well with both. Zinc oxide combines 
well with kaolin, lead, starch, dextrine, and gum. Sulphur combines 
well with the three last named, poorly with kaolin, and not at all 
with lead. Ichthyol suits well with all save the gum pastes. Naphthol, 
calomel, corrosive sublimate, red and white precipitate, carbolic acid, 
chloral hydrate, camphor, and salicylic acid can be incorporated with 
all, the last named in smaller proportion with gum paste. Tar is 
better united with starch, dextrine, and gum, than with the others. 
Iodine and iodoform naturally do not suit well with the starch and 
dextrine pastes. Chrysarobin and pyrogallol are united with kaolin 
and gum pastes, but acids in general destroy the adhesiveness of the 
gum pastes and should not be added to them. Fatty and soapy 
substances, if commingled in large amounts with these pastes, injure 
their special properties. 

Powders are mechanically dusted over the surface of the skin for 
the purpose of protecting it, and occasionally in order, also, to pro- 
duce an astringent or anti-pruritic effect. In order to be serviceable, 
they should generally be rendered impalpable by sifting them care- 
fully through a fine silk bolting-cloth. They are composed of starch, 
magnesia, lycopodium, bismuth, boric acid, camphor, tannin, oxide of 
zinc, iodoform, salicylic acid, and similar substances. The articles 
sold by grocers as "Oswego Gloss Starch" and "Corn Starch Farina" 
are usually much more finely bolted than the dusting-powders extem- 
poraneously prepared by chemists. As absorbent powders, the starchy 
substances are open to the objection of forming little pasty rolls or 
"cakes," when wet with serum or sweat. Lycopodium, which is 
seen under the microscope to consist of irregularly globular pollen 
sporules, never behaves in this way, and is, for that reason, deservedly 
popular. 

Dr. Faithful, of Australia, has recently suggested the preparation 
of medicated powders by first dissolving them in alcohol, ether, or 
chloroform. The solution is then mixed with starch or French 
chalk. Evaporation of the menstruum is conducted without artificial 
heat, and a fine, medicated starch or chalk powder results. 

Plasters are employed when it is desired to exert a more or less 
continuous effect upon the skin, and are thus necessarily consistent 
and desirable. The resin plasters are less useful in skin diseases, 
because more irritating than the lead plasters. Unna's plaster-mulls 
are described below. The mercurial plasters are useful, especially in 
syphilitic lesions of the skin. 

A valuable addition to the list of methods for applying medicated 
ointments to the skin has been devised by Unna. His Salve-muslins 



84 GENERAL THERAPEUTICS. 

or salve-mulls are strips or bandages of muslin thoroughly impreg- 
nated and thickly spread with ointments medicated by almost every 
desirable substance, from the oxide of zinc to tar, thymol, salicylic 
acid, and mercury. They are elegantly made, and, when imported 
to this country, surrounded by impermeable tissue, so as to be quite 
fresh and sweet when used. They are efficacious, and, as a rule, well 
liked by patients. The chief objection to their general employment 
in this country is the expense of importation. The author has used 
them with great advantage in skin diseases of the exudative class 
affecting the extremities. 

Unna's "Plaster-mulls" seem to be less useful. They are 
plasters thinly spread on gutta-percha cloth, and manufactured with 
a wide range of medicinal constituents. They serve a good purpose 
in the protection of parts of the skin exposed to friction. 

Lanolin, or wool-fat, was first introduced as a salve-base by Dr. 
Oscar Liebreich, of Berlin. It is a peculiar substance obtained from 
keratinic tissues, and contains cholesterin fat instead of glycerine, 
with but thirty per cent, of water. It has a bright yellowish color, 
a distinct odor of the sheep, and is neutral, never, when pure, acid in 
reaction. The Berlin specimens that first came to this market 
required the addition of from ten to twenty per cent, of an ordinary 
fat in order to overcome the consistency of the lanoline. But, in 
1886, Prof. Liebreich called attention to a lanolinum purissimum 
which he had substituted for the former, and which, being free from 
cholesterin compounds, required no such fatty addition. 

This substance seems now to have outlived the period both of 
extravagant praise and denunciation. It is readily absorbed from 
the surface of the skin, and, either pure or medicated, may be 
reo-arded simply as a useful addition to the bases of ointments for 
employment upon the skin. 

The Oleates of zinc, mercury, copper, lead, and other metals have 
been employed with advantage in the topical treatment of disorders 
of the skin. Of these, the oleates of mercury and lead are decidedly 
the most valuable. The latter is represented by Hebra's white 
diachylon ointment. The oleate of mercury is serviceable in syph- 
ilitic, parasitic, and other disorders. 

Collodion and Traumaticine are employed for the purpose of 
applying a remedy to the skin, and at the same time protecting or 
contracting the surface to which the application is made. Traumati- 
cine is the name given to a solution of gutta-percha in chloroform, 
in the proportion of ten per cent. In this way bismuth, cantharides, 
sulphur, chrysarobin, oxide of zinc, white precipitate, iodine, and 
other substances may be with advantage applied to the surface, and 
the action of each definitely limited to the margins of a single patch 
of disease. 

The several varieties of Tar, crude and distilled, together with its 
derivatives, occupy an important place among efficient topical agents. 
In general, they seem to exert upon the epidermis a local influence, 
which extends more deeply as the remedy is continuously applied. 



GENERAL THERAPEUTICS. 85 

At times, both irritative and inflammatory effects are thus induced ; 
and when absorption from the skin occurs, even systemic intoxication. 
Pix liquida, or the oleum picis, is the favorite article of this group 
with most American physicians ; but the oleum cadini or oil of 
juniper, and the oleum rusci or oil of birch, are rather more generally 
employed by experts. The last-named, found in purity and abun- 
dance, and to be had at a low price in our own markets, is recom- 
mended above the others. In Vienna the distilled oil is preferred ; 
but there is good reason to believe that the crude oil is decidedly 
more efficacious. 

The skill of a physician entrusted with the management of a dis- 
ease of the skin might almost be measured by his success in the use 
of tar. He who has not had experience in its employment is urgently 
advised to select one member of the tar family and learn thoroughly 
how to apply that, singly and in combination, either in lotion or 
salve. Properly employed, it will favor involution of lesions, less- 
ening hypersemia, infiltration, scaling, and discharge. It serves 
admirably as an antipruritic. As indicated above, it may, however, 
produce severe inflammation of the skin. 

To produce the benign or emollient effects of tar, it is best mixed 
with some soothing or astringent powder, and with this end in view 
nothing is better than chalk. Spender's hints 1 for making such an 
ointment are admirable. Finely levigated chalk is strewed into 
melted lard in a stone jar, the whole being stirred till it is cold. 
Then at first the smallest quantity of tar sufficient to make a brownish 
smear of color is added to the quantity of salve employed for use. 
This color can be successively deepened at will. Auspitz advises the 
use of the tars in a pure state, applied in very small quantities with 
a strong bristle-brush and well rubbed in. In combination with one 
of the most valuable of all substances for topical use in cutaneous 
therapeutics, viz., sulphur, tar enjoys a special reputation. The 
Wilkinson salve modified (q. v.) represents such a combination. 

Ichthtol, fish-oil, sulpho-ichthyolate of sodium or ammonium, 
introduced to the profession by Dr. Unna, is the distillate of a bitu- 
minous and sulphurous deposit of petrified fishes and marine fossils 
found in Tyrol. Its chemical formula is C 26 H 36 S 3 ]Sra 2 6 . It has a 
tarry appearance, odor, and consistency. It is soluble in water, 
partly so in ether and alcohol, and can be incorporated in any desired 
proportion with fat, vaseline, and lanolin. It has been used both 
pure and diluted; and several proprietary articles (plasters, soaps, 
salves, and medicated cotton) are sold in the market. It has been 
used both at home and abroad in cases of leprosy, pruritus, acne, 
sycosis, eczema, psoriasis, and a number of other cutaneous disorders. 2 
It is used in solutions and salves of from ten to twenty per cent, 
strength. As before stated, it is also administered internally, more 

1 Practitioner, June, 1883, p. 402. 

2 See Baumann and Schotten : Monatsh. f. Prakt. Derm., 1883. Unna : same journal, 1882; Deut. 
med. Zeit., 1883. Samml. klin. Vort., 1885 ; Lorenz; Deut. med. Wocn., 1885 ; Stehvagon and Pif- 
fard : Journ of Cut. and Ven.*Dis., 188*5 ; Zeisler: Chicago Med. Journ. and Exam , 1886. 



86 GENERAL THERAPEUTICS. 

particularly in the management of rheumatism, in doses of from 
fifteen to twenty drops. Ir doc- not seem to have a disturbing effect 
upon the stomach. 

This substance has not yet been employed to an extent sufficient 
to establish its position firmly as a remedial agent in diseases of the 
skin. Personal employment of it in a series of different cases, the 
greater Dumber being of eczema and lupus, led to the impression that 
it was not superior to tar in a therapeutic sense. It will probably 
secure a place among the useful article- in this list. 

Unpleasant results have been reported as following its application 
in a single instance (Sinclair). A four-months old infant sank into 
a state of stupor two hours after its head and limbs were smeared 
with a salve composed of one part of ichthyol to five of vaseline. 

A group of substances which occupy a therapeutical position inferior 
to the tars, but which serve an important end in the management of 
cutaneous diseases by the production of similar effects, are, carbolic 
acid, creasote, salicylic acid, benzol, naphthol, iodol, chrvsarobin, 
pyrogallol, resorcin, and jequirity. 

'Resorcin in ointments of the strength of five to twenty per cent, 
serves as an antipruritic and alterative. Dr. Stelwagon reports an 
anodyne effect following its use. This same experimenter has 
modified Ihle's formula by adding a drachm (4.) of resorcin to one 
to two drachms (4.-8.) of castor-oil, five minims (0.33) of Peru- 
vian balsam and four ounces (128.) of alcohol, for use in alopecia 
and seborrhoea of the scalp. It is a valuable parasiticide in lotions 
of the strength of from five to ten per cent. 

Naphthol, or /3 naphthol, as it is termed chemically, first intro- 
duced by Kaposi, has fairly retained its place in the list of efficient 
topical remedies. It is chiefly valuable in scabies, but has also been 
used in the management of eczema, psoriasis, and other exudative 
affections. Van Harlingen 1 has found it answer well in seborrhoea 
of the scalp. Xeisser has described renal disorders as resulting from 
its use in children, but MM. Josias and Nocard 2 report that in ordi- 
nary medicinal doses it is harmless. The fact that the naphthol 
preparations are odorless and do not stain the skin is to be set down 
in their favor. 

Jequirity (abrus precatorius), employed by ophthalmologists for 
the purpose of inducing artificial inflammation of the conjunctiva, has 
been used by Dr. Shoemaker 3 in the management of lupoid and other 
ulcers. One part of the cleansed, decorticated, and bruised grains, 
macerated for twenty-four hours, and reduced by rubbing in a mortar 
to a smooth paste, was added to sufficient water to make four parts. 
This emulsion was used for local application. 

Sulphur, employed popularly chiefly as a laxative or for the local 
treatment of scabies, has also a deserved reputation in cutaneous 
therapeutics, as an external agent in a wide range of non-parasitic 

i Amer. Journ. of the Med. Sci., Oct. 1883. - Ann. de Derm, et de Sypu., May, 1885. 

3 Lancet, Aug. Is*--), p. 186. » 



GENERAL THERAPEUTICS. 87 

disorders. Hebra once regarded it as valueless in eczema, but his 
opinions on this point are not now generally accepted. The precipi- 
tated sulphur is to be preferred to the other compounds of the phar- 
macopoeia. It may be mechanically incorporated with salve-bases or 
chemically combined with vaseline and other petroleum products, a 
process by which experiments have led the author to believe its 
therapeutic value is not increased. It is also applied after mechani- 
cal union with various substances as a lotion. It is irritating to 
the acutely inflamed skin, but much better tolerated in conditions of 
subacute or chronic exudation than the tars. 

Mercury and its compounds are of value in the local treatment of 
many disorders of the skin, syphilitic and not syphilitic. Corrosive 
sublimate as a parasiticide is of great importance in the treatment of 
several cutaneous disorders due to the presence of bacteria, as, for 
example, lupus vulgaris. Calomel, the oxides, iodides, and the 
ammonio-chloride, are chiefly used in the form of ointments, but 
the black wash, prepared with the mild chloride, is of great value 
in eczema. Piffard 1 has called attention to the fact that the officinal 
ointment of white precipitate is made with pure lard instead of as 
formerly with lard and wax ; and to this change, tending to hasten 
the absorption of the mercurial, he attributes some late failures with 
this admirable salve. Disagreeable dermatitis followed by scaling 
has been reported to follow its use in the strength of forty grains 
(2.66) to the ounce (32.) by Mr. W. E. Green, of Londou. 2 

Chloral-camphor and Phenol-camphor have value chiefly as 
antipruritics. The former is obtained by rubbing together the hydrate 
of chloral and gum-camphor (Bulkley) till they form a clear liquid 
of pungent odor. Phenol-camphor is made by gradually adding 
camphor to melted crystals of carbolic acid, a colorless liquid resulting 
having the fragrant odor of camphor without that of the acid. It is 
a useful local anaesthetic agent, being insoluble in water, but freely 
soluble in chloroform, ether, and alcohol. 

Many Agents are employed upon the surface of the integument to 
produce in various degrees a Caustic or Destructive effect. Among 
these may be named the thermo-cautery (Paquelin knife), galvano- 
caustic apparatus, the mineral acids and alkalies, ethyla^e of sodium, 
arsenic, chloride of zinc, several mercurial compounds, acid nitrate of 
mercury, bichloride of mercury, chloride of antimony, sulphate of 
copper, and nitrate of silver. Several of these substances in weak 
solution are employed as milder agents for the production of irritative, 
or even various inflammatory, effects. To the latter class should be 
added iodine in tincture, chloroform, tartar emetic, croton oil, and 
cantharides. 

These destructive effects are of advantage in the treatment of dis- 
orders of the integument due to parasites, either animal or vegetable. 
Of those employed for this purpose, and not mentioned above, may 
be named petroleum and staphysagria, for the destruction of lice ; 

i Journ. of Cut. and Ven. Dis., Oct. 1866. 2 Brit. Med. Journ., 1885. 



bo GENERAL THERAPEUTICS. 

sulphur, styrax, and balsam of Peru, for the destruction of acari; 

sulphur and its compounds, and a number of derivatives from tar' 
for the destruction of vegetable parasites. 

A variety of Surgical and other Appliances are found useful as 
adjuvants in the treatment of skin diseases. They may be employed 
to support, protect, or compress the surface, or merely to aid in 'the 
retention of dressings or external medicaments. Thus the ordinary 
roller bandage is applicable to many portions of the body; the sus- 
pender, or suspensory bag, over the scrotum; elastic or inelastic 
Stockings to the feet and legs; kid, rubber, and thread gloves to the 
feet and fingers ; and various skull-caps, face-masks, and mittens are 
employed in the case of infants and children to protect affected 
surfaces from the dangers of scratching. 

It is an axiom in dermatology that a salve is worth far more to 
the patient when it is spread on muslin, and thus retained in contact 
with the skin, than when it is merely smeared or rubbed over the 
surface. It is this important feature which has doubtless contributed 
so largely to the reputation of Unua's salben-mulle, or salve-muslins. 
In order to secure the retention of such salve-spread muslins in con- 
tact with the surface, the common muslin roller, which exercises more 
or less compression, is inferior to the light and more pervious cheese- 
cloth bandage. This is especially true when the' dressing is made by 
the patient, who is, in general, far less expert than either the trained 
nurse or the physician. 

Apart from the surgical apparatus required for ablation of tumors 
or other severe operations, a number of instruments are required for 
the daily use of the dermatologist. Among these may be named : 

A set of variously sized dermal curettes. These sharp-edged spoons 
are for erasion of the surface, and should consequently have in each 
a fenestrum large enough to permit the escape of all collected sub- 
stances from the floor of the spoon. 

Epilating forceps with easy springs and smooth blades meeting in 
perfect apposition. 

A set of Piffard's comedone extractors, provided at each extremity 
with a differently sized, minute, spoon-shaped, and perforated bowl, 
the convex surface of which is pressed over the comedo with the 
orifice immediately over the black head of the plug. This is a great 
improvement over the old-fashioned comedo extractor shaped like a 
watch-key, and the discomfort to the patient is by its use greatly 
reduced. 

A set of half-inch and four-inch leuses for examining the surface 
of the skin. 

Needle-holders with light handles for firmly grasping needles for 
use in opening pustules, etc. The latter should be, some of them 
flat with a double-cutting edge, others rounded neatly on an emery- 
wheel, and all of them very carefully disiufected if used more than 
once. Too many precautions cannot be taken in the practice of 



GENERAL THERAPEUTICS. 



89 



dermatology, with respect to the disinfection of all instruments made 
to penetrate the skin. 

Fig. 18. 



Irido-platinum needle. 

Fig. 19. 

Milium needle. 

Fig. 20. 

Scarifying spud. 

Fig. 21. 



Epilating forceps. 

Fig. 22. 




Piffard's grappling forceps. 

Fig. 23. 




Skin grafting scissors. 

Fig. 24. 




Piffard's cutisector. 



90 



CLASSIFICATION 
Fig. 25. 




Dermal curettes. 

Fig. 26. 



Hess's glass pleximeter. For observing the skin under pressure. 
Fig. 27. 




modification of Unna's comedo extractor. 



Fig. 28. 



'^4 OF REAL SIZE. 

Keyes' cutaneous punch. 

Probes, exploring needles, fine dressing-forceps, delicate straight 
and curved scissors, and other instruments from the ordinary pocket- 
case of the surgeon, are indispensable. The instruments required for 
use in connection with the galvanic battery are enumerated in the 
chapter on hirsuties. 

For detection of different degrees of temperature at the surface, the 
author has employed for several years the thermo-electric differential 
calorimeter. The thermopiles of this apparatus act upon a galva- 
nometer needle suspended by a single filament of the cocoon of the 
silk-worm, and it is thus as sensitive as is required for the most 
delicate observations. 



VII. 

CLASSIFICATION. 

The numerous attempts which have been made to classify diseases 
of the skin according to their nature and relations, have been a 
response to the generally recognized demand for a systematic arrange- 
ment of all scientific facts. As regards dermatology, not only have 



CLASSIFICATION. 91 

these attempts been numerous and based upon different principles, but 
the results which they have accomplished have been in the highest 
degree divergent. No single classification yet devised has hitherto 
secured general acceptance. While it is certain that no one of them 
has been perfect and that each has exhibited defects, it is equally true 
that of the larger number each has possessed some merit of its own. 
No perfectly satisfactory classification of cutaneous diseases can be 
generally accepted till the knowledge of diseases of the skin has been 
greatly enlarged. 

One of the most satisfactory of the systems thus far proposed is 
that of Hebra. By it cutaneous disorders are arranged in the 
following nine classes : 

Class I. Disorders of Secretion. 

Class II. Hyperemias. 

Class III. Exudations. 
Class IY. Hemorrhages. 

Class Y. Hypertrophies. 

Class YI. Atrophies. 

Class VII. New Growths. 
Class VIII. Neuroses. 

Class IX. Parasites. 

Since this classification was devised by Hebra, none has been pro- 
posed which compares in ingenuity with the arrangement by Auspitz 
of the diseases of the skin into natural groups. The principle of this 
classification is to place together those diseases and groups of diseases 
which present a clinical unity ; the general pathological process being 
the predominant characteristic for selection, and individual patho- 
logical characteristics, such as symptoms, localization, anatomical 
peculiarities, etc., are only brought thus predominantly forward when 
coinciding with the real nature of the class, group, or disease in 
question. 1 

Auspitz's nine classes are: 1. Simple Inflammatory Dermatoses ; 
2. Angioneurotic Dermatoses ; 3. Neuritic Dermatoses ; 4. Stasis 
Dermatoses; 5. Hemorrhagic Dermatoses; 6. Idioneuroses ; 7. Epi- 
dermidoses ; 8. Chorio-Blastoses ; 9. Dermatomycoses. 

. Under these classes, by the aid of divisions and subdivisions, an 
elaborate scheme is presented, which embraces fully not only all 
cutaneous diseases, but all pathological processes recognized in the 
skin. This system, accepted with modifications by Hans Hebra, 2 has 
unquestionably been followed by a greater advance in the nosology of 
cutaneous medicine than any of those which have been proposed since 
Hebra first offered his. 3 

1 System d. Hautkrankheiten. Wien, 1881. 

2 Die Krankh. Veranderung. der Haut. Braunschweig, 1884. 

3 An exceedingly ingenious and comprehensive scheme of classification of diseases of the skin, 
embracing most of the principles upon which the best of previous classifications were based, was pre- 
sented by Dr. E. B. Bronson, of New York, at the meeting of the American Dermatological Association, 
in August, 1887. 



92 CLASSIFICATION. 

Auspitz's classification is, however, open to various objections on 
the part of the student of dermatology. It is elaborated to the 
extent of setting the names of some diseases in more than one family; 
and is, hence, confusing to the beginner. It is bettor adapted to the 
needs of the expert than of the young student, for it introduces to 
the study rather of morbid processes in the skin than of the com- 
plexus of those processes which are recognized in disease. 

Whether the principle of classification be anatomical, etiological, 
or pathological ; whether it be based on the processes actually occur- 
ring in the skin, or on those deeper factors and forces operating oen- 
trifugally upon the skin, and on which that organ depends for all its 
functions and even its existence ; whether it proceed etiologically 
from the causes which are immediate, or those which are remote, it is 
easy to see that, as knowledge in each of these directions enlarges, 
the exact position of any one disease in any given classification must 
be rendered insecure. Never was this observation more suggestive 
than at this day, when the pathogeny of numerous skin disorders is 
revealed in the light thrown on the subject by the discovery of new 
and hitherto unknown inferior organisms. 

Indeed, to this last cause, awaking grave doubts as to the precision 
of much that was once esteemed fact, may be attributed the declining 
interest in the general subject of classification of diseases of the skin. 
The earnest discussion of this theme has been practically deferred by 
common consent to a date when the questions thus suggested can be 
more satisfactorily answered. Several recent writers have actually 
contented themselves with an alphabetical arrangement of the names 
of skin diseases, 1 as an order useful simply for reference. 

The classification observed in this edition of this work is that 
adopted by the American Dermatological Association, August 29, 
1878, and revised by the same body, August 28, 1884. It is that 
of Hebra modified. Its claims on American students cannot be 
ignored. It has been presented and adopted by the recognized expo- 
nents of Dermatology in America. It has been made for nearly ten 
years the basis of dermatological study in some of the leading 
medical schools of this country. It is not claimed for it that it is a 
perfect system, but one in which the names of many disorders have 
merely a provisional position. It will, without question, be revised 
from time to time, by the body which first gave it to the world, and 
which by its aid has fostered the study of cutaneous medicine in 
America as it was never fostered before. It is employed here as a 
valuable, convenient, and accepted nosological scheme, in which, it is 
distinctly admitted, a rearrangement of many terms is demanded 
from year to year by the advances of science. 

1 Van Harlingen : Handbook of the Diagnosis and Treatment of Skin Diseases. Phila., 1S34. 



CLASSIFICATION. 



98 



CLASSIFICATION OF DISEASES OF THE SKIN ADOPTED BY 
THE AMERICAN DERMATOLOGICAL ASSOCIATION. 



-Class I. Disorders of the Glands. 


e. pustulosum. 


1. Op the Sweat Glands. 


/. rubrum. 


Hyperidrosis. 


g. squamosum. 


Sudamen. 


Prurigo. 


Anidrosis. 


Acne. 


Bromidrosis. 


Acne rosacea. 


Chromidrosis. 


Sycosis. 


Uridrosis. 


Impetigo. 


2. Of the Sebaceous Glands. 


Impetigo contagiosa. 


Seborrhcea : 


Impetigo herpetiformis. 


a. oleosa. 


Ecthyma. 


b. sicca. 


Pemphigus. 


Comedo. 




Cyst: 


Olass III. Hemorrhages. 


a. Milium. 


Purpura : 


b. Steatoma. 


a. simplex. 


Asteatosis. 


b. hemorrhagica. 


Olass II. Inflammations. 

Exanthemata. 


Olass IV. Hypertrophies. 

1. Of Pigment. 


Erythema simplex. 
Erythema multiforme : 


Lentigo. 
Chloasma. 


a. papulosum. 

b. bullosum. 

c. nodosum. 
Urticaria. 

pigmentosa. 


2. Of Epidermal and Papil- 
lary Layers. 
Keratosis : 

a. pilaris. 

b. senilis. 


Dermatitis i 1 

a. traumatica. 

b. venenata. 

c. calorica. 

d. medicamentosa. 


Molluscum epitheliale. 

Callositas. 

Clavus. 

Cornu cutaneum. 

Verruca. 


e. gangrenosa. 


Verruca necrogenica. 


Erysipelas. 

Furunculus. 

Anthrax. 

Phlegmona diffusa. 

Pustula maligna. 

Herpes simplex. 

Herpes zoster. 

Dermatitis herpetiformis. 

Psoriasis. 

Pityriasis maculata et cir- 

cinata. 
Dermatitis exfoliativa. 
Pityriasis rubra. 
Lichen : 


Nsevus pigmentosus. 
Xerosis. 
Ichthyosis. 
Onychauxis. 
Hypertrichosis. 
3. Of Connective Tissue. 
Sclerema neonatorum. 
Scleroderma. 
Morphoea. 
Elephantiasis. 
Rosacea : 

a. erythematosa. 

b. hypertrophica. 
Frambcesia. 


a. planus. 




b. ruber. 
Eczema : 


Olass V. Atrophies. 


1. Or Pigment. 


a. erythematosum. 


Leucoderma. 


b. papulosum. 

c. vesiculosum. 


Albinismus. 

Vitiligo. 

Canities. 


d. madidans. 


i Indicating affectioDg of this class not properly 


2. Of Hair. 


'included under other titles. 


Alopecia. 



94 



CLASSIFICATION 



Alopecia furfuracea. 
Alopecia areata. 
Atrophia piloram propria. 
Trichorexis nodosa. 

3. Of Nail. 

Atrophia unguis. 

4. Of Cutis. 

Atrophia senilis. 

Atrophia maculosa et striata. 

Class VI. New Growths. 

1. Of Connective Tissue. 

Keloid. 

Cicatrix. 

Fibroma. 

Neuroma. 

Xanthoma. 

2. Of Muscular Tissue. 

Myoma. 
.">. OF VEB8ELS. 

Angioma. 

Angioma pigmentosum et 
atrophicum. 

Angioma cavernosum. 

Lymphangioma. 
4. 

Rhino-scleroma. 

Lupus erythematosus. 

Lupus vulgaris. 

Scrofuloderma. 

Syphiloderma : 



a. erythematosum. 

b. papillosum. 

c. pustulosum. 

d. tuberculosum. 

e. gummatosum. 
Lepra : 

a. tuberosa. 

b. maculosa. 

c. amesthetica. 
Carcinoma. 
Sarcoma. 

Class VII. Neuroses. 
Hyperesthesia: 

a. pruritus. 

b. dermatalgia. 
Anaesthesia. 

Class VIII. Parasitic Affections. 

1. Vegetable. 

Tinea favosa. 

Tinea trichophytina : 

a. circinata. 

b. tonsurans. 

c. sycosis. 
Tinea versicolor. 

2. Animal. 

Scabies. 

Pediculosis capillitii. 
Pediculosis corporis. 
Pediculosis pubis. 



DISEASES OF THE SKIN. 



CLASS I. 



DISORDERS OF THE GLANDS. 

In this class of disorders are grouped all the functional disorders 
of the sweat or coil-glands, the sweat pores, and the sebaceous glands. 
These disorders may be betrayed in quantitative or qualitative 
changes in the secretion, or in retention of the latter in the whole or 
in a part of the secretory apparatus. When a disease of the skin 
ceases to be purely functional in type, and is accompanied by an 
exudative process, glandular or periglandular in situation, such 
disease is properly classed with another and in this particular related 
group of affections. 



1. Of the Sweat Glands. 
Hyperidrosis. 

Gr. imep, in excess ; vdup, water. 

Hyperidrosis is an exaggerated quantitative effusion of sweat, the secretion 
accumulating in visible drops upon the surface of the skin. 

Symptoms. — This condition, also termed Idrosis, Hydrosis, 
Ephidrosis, Sudatoria, Polyidrosis, and Hyperhidrosis, may be 
physiological as the result of active exertion in a medium of high 
temperature ; or it may be pathological in character, and in the latter 
case be either general or partial. 

General sweating to a pathological extent occurs chiefly in the obese, 
but also in those who are the subjects of constitutional disease (phthisis, 
the various febrile disorders, etc.). It is the fertile source of the 
various forms of intertrigo, sudamina, and miliaria. Local hyperi- 
drosis is the exaggerated quantitative effusion of sweat limited to certain 
definite portions of the skin, as the palms, soles, dorsa of the hands 
and feet, the interdigital spaces, the genitals, the axillse, and temples. 
In such cases the secretion occurs moderately or greatly in excess, 
varying in this respect somewhat in different degrees of temperature, 



96 DISEASES OF THE SKIN. 

and of rapidity of the circulation ; is occasionally, but not commonly, 
accompanied by fetor; and always occurs to a marked extent. It 
may involve one or both sides of the body, being generally symmet- 
rical at the extremities, and asymmetrical* upon portions of the face. 
[ts topical expression may be studied in the hands, which are con- 
tinually moistened, clammy, or dripping with fluid within a brief 
time after the most careful drying of the parts. In the case of a 
woman, the instincts of whose sex prompt her to take such precautions, 
the dress is constantly protected from contact with the macerated 
palms by a handkerchief or similar article which is always in readi- 
ness. The disadvantages thus arising in individuals of both sexes 
who are engaged as tradespeople, artists, hand workers, etc., can 
be readily estimated. In women of social position, no small coin- 
plaint is made of the disagreeable result produced after wearing kid 
gloves for even a short time, the material of which is soon soiled by 
its complete saturation with the secretion from the skin. 

With and without this local excess, occurs the hyperidrosis of the 
feet, aggravated by the mechanical force of gravity and the need of 
constant covering. The stockings and the leather of the boots, shoes, 
or gaiters are saturated with the secretion, and become rapidly subject 
to chemical alteration. There is usually an offensive odor of the 
region, originating partly in the primary' fetor of the secretions them- 
selves, and partly in the subsequent chemical decomposition of the 
latter, rapidly progressing under the influence of the soiled and often 
stinking investments of the feet. 

The integument, constantly macerated, may become both painful 
and tender ; very rarely there is vesiculation or exfoliation of patches 
of sodden epidermis. When the genitals are involved, especially in 
the male, erythema and intertrigo are the frequent results. 

Etiology. — The disease may be in rare cases congenital. In others 
it is associated in one person with disorders not apparently related to 
it. The author has at present in hospital a woman, twenty-four 
years of age, affected with severe tylosis of the feet, from which are 
exfoliated extensive lamellated casts of the soles. She also has tvpical 
hyperidrosis of the hands. 

In no portion of the nervous system has a localized centre for 
excito-sudoral or inhibitory effects been recognized. Traumatisms, 
gliomata, gummata, scleroses, and other lesions affecting the cerebrum, 
medulla, cord, ganglia, and trunks of the sympathetic nervous 
system have been followed by local and general hyperidrosis, but they 
have all repeatedly failed to induce such morbid sudoral symptoms, 
while a fit of anger or sudden fright has been as conspicuously 
effective as any. In short, the predominant influence of the nervous 
system in an etiological sense must be admitted here as in physio- 
logical sweating : and the sympathetic branches of that system must 
be assigned the greater influence for the most cases. A paralysis or 
paresis of the sympathetic is held to explain the occasional coincidence 
of pulmonary and cardiac disorders, with either general or partial 



HYPERIDROSIS. 97 

excessive sweating. Compression of the sympathetic by adenomata, 
aneurisms, carcinomata, etc., has been followed by marked symptoms 
of this disorder. The disease is encountered in individuals of both 
sexes, and in all ages and degrees of general health, as also in those 
who are and those who are not careful as to cleanliness. There is 
reason to believe that the facial asymmetrical hyperidroses associated 
with migraine, neuralgias, hemicrania, etc., are etiologically and 
pathologically distinct from the similar symmetrical affections of the 
hands and feet. The latter certainly occur with conspicuous frequency 
in young women who are the subjects of hysteria, chloro-ansemia, 
some form of dysmenorrhoea, or cardiac trouble. In one young 
svoman under the author's observation, there was an habitual pulse 
of fifty-five to the minute without dicrotism, the patient being in 
other respects well. 

Pathology. — Robinson, who has examined a number of sections 
from the palm of the hand, failed to detect any abnormal feature 
either in the glands or the epithelium. The disorder is to be regarded 
as purely functional ; and any anatomical changes in the coil-glands 
or sweat-pores are probably accidents of such derangement of 
function. 

Treatment — When universal, hyperidrosis is to be treated inter- 
nally by the aid of such remedies as are indicated by the general 
condition of the patient. The various ferruginous tonics, mineral 
acids, arsenic, strychnia, quinine (the latter particularly when, as is 
often the case, a malarial affection is responsible for the disorder), and 
ergot, with both belladonna and atropine, are all of unquestionable 
value. Even though but temporarily serviceable, belladonna and 
atropine are well used at the outset of most cases. Aconite, jabor- 
andi and pilocarpine, white agaric (agaricine is recommended in 
doses of one-sixth of a grain (0.01 1), repeated as required), carbolic 
and salicylic acids may be named as in the second rank. 

External treatment is often promptly efficacious, and can rarely be 
neglected in any case. The simplest method , is by wiping, not 
washing, the surface until it is dry, and applying the dusting- 
powders, such as lycopodium, talc, salicylic acid, boric acid, bismuth, 
magnesia, hydrate of chloral one part to five or six of starch, and 
starch itself, the chief objection to the latter being its tendency to 
form cakes or rolls after its union with the sweat. Alternately with 
these, or in lieu of them, baths or lotions' may be employed, aqueous 
or alcoholic, and medicated with corrosive sublimate, tannic acid, zinc 
sulphate, alum, permanganate of potassium, or the sea salt now sold 
in packages for domestic use. Dr. G. H. Fox 1 advises a lotion 
containing one part of quinine to one hundred of alcohol. Van 
Harlingen recommends the use of juniper tar or carbolic acid soap 
with the bath, as alone sufficient to relieve some cases. 

For hyperidrosis of the feet, the treatment by the method of 

1 Journ. of Cutan. and Ven. Dis., 18S5, p. 24 

7 



98 DISEASES OF THE SKIN 

Hebra has, deservedly, high repute. It consists in neatly and com- 
pletely enveloping the entire foot and toes separately, after thorough 
washing and drying, in strips of cotton cloth over which is spread 
to the thickness of the blade of a common knife, the unguentum 
diachyli albi elsewhere described. This latter is made by boiling 
one part of the best litharge with about four parts of pure olive oil, 
to which a little water is added while the materials arc stirred 
together over a slow fire. The parts are well bandaged, and the 
patient either remains subsequently at rest or pursues his vocation, 
wearing over the feet, shoes and stockings which have not been 
previously used. In twenty-four hours, the feet are redressed with- 
out washing, after dry rubbing with charpie and a dusting powder. 
This is repeated daily for ten to twenty days, after which a dusting 
powder may be substituted for the local dressing. A parchment- 
like desquamation of the epidermis in thick, yellowish-brown 
lamella? occurs, beneath which an epidermis is formed, new and at 
first tender, but apparently normal. When the latter has lost its 
tenderness, the feet are for the first time washed with water. In 
case of failure, the routine of treatment is, as often as necessary, 
again carried out. It is scarcely necessary to add that no ill effects 
are known to have resulted from the therapeutic measures adopted 
for checking a local hyperidrosis. 

For the diachylon salve may be substituted tar, ichthyol, or 
naphthol ointments. Fredericq employs finely jDulverized tartaric 
acid, applied at first with some caution, and always in small quanti- 
ties. Stewart first bathes the feet in hot water and then soaks them 
for a few moments, and once only, in a solution of the permanganate 
of potassium, four to six grains to the ounce, (0.266-0.4 to 32.), 
after which, the plaster selected for use may be applied as directed 
above. Legoux orders pediluvia of tar water twice daily, for three 
days, followed by a painting of the feet with a solution of the per- 
chloride of iron. Morrow 1 recommends foot-baths in the extract of 
pinus canadensis, followed by the application of boric acid, or sali- 
cylic acid, mixed with lycopodium. Lastly, Brandon, experimenting 
on the permeability of the skin to ethers and gases, claims to have 
solved the problem of local treatment with a " liquor anti-hidror- 
rhoicus," prepared from the chloric ethers. 

ProcpiOHis. — The future of any case of hyperidrosis is uncertain. 
The disease, whether local or general, may spontaneously disappear, 
recur, be promptly amenable to treatment, or prove obstinate to all 
therapy. Dr. Myrtle 2 reports the case of a male patient, seventy- 
seven years old, who sweat to death after repeated recurrences of 
severe hyperidrosis, and after temporary relief from the use of 
Fowler's solution. 

1 See his ivsume of this subject in the Journ. of Cutan. and Ven. Dis., vol. v. p. 68. 

2 Medical Press, Feb. 25, 1S86. 



SUDAMEN. 99 

Sudamen. 

Lat. sudor, sweat. 

Sudamina are discrete, superficially seated, millet-seed sized and larger, 
translucent vesicles, resembling seed-pearls. 

Symptoms. — In this disorder, also termed Miliaria Crystallina, the 
lesions are thickly agglomerated, but discrete, transitory, and translu- 
cent, pin-point sized vesicles, resembling dew-drops or seed-pearls, 
upon the surface of the skin, often requiring the touch to define 
their real character. They are usually limited to certain regions of 
the body, as the trunk, and here more generally upon the face and 
sides of the belly, and the iliac regions, though they may occur upon 
any part. Their course is rapid, both in evolution and involution, 
and their sequela? are exceedingly delicate desquamative flakes, the 
thin roof-wall which originally covered the sweat-drops having been 
lifted from the superficial stratum of the horny layer of the epidermis. 
They contain each a droplet of sweat, which is removed by evapora- 
tion. They are usually preceded by an attack of pruritus, and may 
follow the hyperidrosis of systemic debility, enteric and continued 
fevers, phthisis, inflammatory rheumatism, pneumonia, and other 
asthenic conditions. They may also result from violent exercise, the 
elevated temperature of the summer season, flannel underclothing, 
vapor baths, and the application of wet and hot cloths to the surface 
of the skin. 

The lesions are the result of the accumulation of sweat between 
the most superficial layers of the stratum corneum, in high tempera- 
tures of the body, or of the medium by which it is surrounded, and 
usually in states of adynamia. They may hence occur at all ages, 
and in both sexes. 

Eobinson states that they form rapidly on the face of laundresses, 
and in women from the thirty-fifth to the fiftieth year of life, where 
also they are isolated and disappear slowly. 

Three forms of sudamina have been described: (a), sudamina 
alba ; (b), sudamina rubra ; and, (c), sudamina crystallina. The 
last-named is the only form to which the term sudamen is properly 
applied, since it alone of the three designates a purely functional 
derangement of the sweat-secreting apparatus. 

The first term, sudamina alba (miliaria alba), is applied to lesions 
where there is maceration of the vesicular wall and the contents be- 
come opalescent. This is rare. The second term, sudamina rubra 
(miliaria rubra, lichen tropicus, "prickly heat"), is applied to in- 
flammatory lesions which may accompany profuse sweating. These 
are numerous pin-point to pin-head sized vesicles surrounded by a 
reddish halo, or papules of the same dimensions, or the two lesions 
commingled, almost invariably accompanied by hyperidrosis, though 
the latter may be absent in high temperatures. The marked 
tingling, pricking, and burning sensations by which they are accom- 



100 DISEASES OF THE SKIN. 

panied, arc often in the highest degree distressing, and may solicit 
rubbing of the affected part, though the scratching elicited by severe 
pruritus is not common. Minute crusts may form after vesicular 
rupture. The attack may be mild or quite severe, and last for a few 
days, or for as many weeks or months, as the result of continuous 
aggravation, or of the production of new crops of lesions after each 
recurrence of the cause. It is not rarely complicated in obese indi- 
viduals, by all varieties of intertrigo and eczema, 

The sudamina crystal Una are, however, the sole lesions which 
may be properly considered in this class of affections. They are 
always free from all inflammatory symptoms, presenting a limpid, 
dew-drop-like aspect that is characteristic. 

Etiology. — The disease is induced by excessive sweating ; often in 
consequence of an elevated temperature; also, however, as a result 
of a systemic asthenia, as indicated above. 

Pathology. — Dr. Robinson has studied the anatomy of the sudamen 
with special care. Its contents are pure sweat without admixture of 
lymphoid corpuscles. The fluid collects between the lamina? of the 
deeper part of the corneous layer. The author supposes a rupture of 
the wall of the sweat-duct, but with our present knowledge of the 
a latomy of this part of the skin, we can see in his illustrations the 
obliterations merely of the sweat-pore by a sudden effusion of watery 
fluids toward the epidermis, which pass with moderate pressure 
through the wall-less sides of the pore into the spaces between the 
epithelial cells, where a chamber is readily formed. 

This is made clearer by the author's exact description of actual 
dilatation of the duct of the coil-gland, where there is "not an escape 
of sweat into the neighboring tissue," which he recognized in the 
corium. The sudamina exhibiting this peculiarity appear on the 
face, chiefly of women. 

Diagnosis. — No difficulty can arise in making a diagnosis, if the 
peculiar characters of the sudamen be kept in view. All pustular 
lesions have different contents; all bullous lesions are larger; or 
seated on an engorged base; or lack the limpid clearness of the 
sudamen, because, however transparent the contents, they are mostly 
covered by a thicker and less transparent roof. The halo about the 
lesions of miliaria rubra, or their rosy-pinkish shade will determine 
their character. In varicella the lesions are chambered. 

Treatment. — Only the simplest treatment is required. The lesions 
may be dusted with one or several of the dusting powders, such as 
starch, lycopodium, or boric acid, named in the chapter on General 
Treatment of Cutaneous Diseases. The general treatment is that 
indicated by the condition of the patient. 

Miliary Fever, or the suette miliaire of the French, is an 
epidemic disorder, accompanied by sweating and a cutaneous exan- 
them. Pineau 1 gives a description of the disease as it occurred in 
epidemic form in the island of Oleron, where, of one thousand patients 

i ArcUiv. Geiu-r. de M<5d., Jan 1882, p. 25, 



ANIDEOSIS. 101 

affected, between one hundred and fifty and two hundred perished. 
The eruption appeared in the form of hyperaamic maculae, disappearing 
under pressure, after which there rapidly formed myriads of reddish 
or whitish, grouped, unequally sized, and acuminate papules, rising 
from a whitish and macerated surface. Among these were inter- 
spersed lesions of sudamina. The region of the face was not spared, 
and the conjunctiva? were occasionally affected. In the course of 
from two to four days, pin-head to bean-sized, varioliform but non- 
umbilicated pustules formed in the site of some of the papules, the 
contents of which disappeared by resorption, the final lesions pre- 
sented being large, flat, reddish papules, the skin, of the face particu- 
larly, becoming generally reddened and. swollen. In the course of 
from ten to twelve days, general desquamation ensued with large 
palmar and plantar losses. Relapses occurred in some cases with 
general redness of the surface, or with crops of reddish plaques, or 
yet again with the occurrence of furuncles. The sensations were those 
of myriads of needles thrust into the skin. The exanthem was accom- 
panied in some cases by fever, and in others not. In fatal cases death 
resulted from exhaustion. 

Geber, however, and other writers believe that the lesions described 
are not peculiar to any special disease; and deny the possibility of an 
independent miliary fever. 



Anidrosis. 

Gr. a, privitive ; vdap, water. 

This name is properly applied to those morbid conditions where no sweat is 
secreted from the surface of the body. The word Hypohidrosis is more 
exactly used to designate a relative, general or partial decrease in the quan- 
tity of the sudoral fluid. The former term is, however, often used to include 
the latter. 

Complete anidrosis occurs naturally only when the sudoral appa- 
ratus has been involved in destructive or other changes in the skin 
(scars, atrophy, etc.). 

Diminution in the quantity of sweat excreted, or its complete sup- 
pression, whether general or local, is a symptom of several disorders, 
but as a separate cutaneous affection has no existence. It is suffi- 
ciently common in many cutaneous diseases, as, for example, ichthy- 
osis, psoriasis, and some forms of eczema. But in these, the symp- 
tomatic character of the anomaly is illustrated by the well-known 
fact that when the skin is relieved of these cutaneous troubles, the 
function of sweat secretion is restored. Similarly, in neuralgias and 
certain forms of paralysis, a circumscribed and temporary anidrosis 
may be the local expression of the nervous disturbance, precisely as 
in the case of the asymmetrical hyperidroses. Lastly, there are indi- 
viduals exhibiting the idiosyncrasy of sweating either not at all or 
quite imperceptibly in elevated temperatures, phenomena which 



102 DISEASES OF THE SKIN. 

should be ascribed rather to peculiarities In the equilibrium of the heat- 
exchanging forces, than to congenital deficiency of the sweat-glands. 

According to Geber, Strauss and Bloch regard the occurrence of 
hypohidrosis and anidrosis as differential diagnostic symptoms of dif- 
fuse myelitis and poliomyelitis as against cerebral paralysis. 

Treatment. — The measures capable of stimulating the sweat secre- 
tion are: the ingestion of water in quantity by the mouth, the ex- 
ternal application of heat in a dry or moist atmosphere, and the use 
of jaborandi or pilocarpine by the mouth or hypodermatic injection. 
In the anidrosis accompanying cutaneous disease, the indication is 
always primarily for the relief of the latter. 



Bromidrosis. 

Gr. /3pw ( «or, a stench ; vSup, water. 

This disorder is also termed Bromhidrosis, Osmidrosis, and fetid or stinking 

sweat. 

Symptoms. — Here the perspiration is effused in such a state that it 
can be immediately perceived to possess an unusual odor, or, as Hebra 
taught was the case with the majority of patients, to be rapidly changed 
to that condition. It is often associated with hyperidrosis, or may 
occur quite independently of the latter, and like the latter also be either 
general or partial. The odor may be either agreeable or disagreeable, 
having been in various cases compared to that of several flowers and 
fruits, as well as to that of various stench-emitting animals. Iu this 
respect the sweat presents a striking analogy to the urine, with which 
it sustains a close and well-recognized physiological relation. 

General bromidrosis may be physiological, as in the case of indi- 
viduals of the African race, or in those of dark skins who are pro- 
fusely sweating during labor or in exalted temperatures. General 
pathological bromidrosis is rare. The odors emanating from the 
person in ulcerating syphilodermata, smallpox, aud other general dis- 
orders, may, in certain cases, be associated with the sweat secretion, 
but in others doubtless are connected with the decomposition of patho- 
logical products of the inflammatory process. 

The local varieties of bromidrosis affect the regions in which the 
sweat is oftenest secreted in excess, and its immediate evaporation 
prevented, as in the axillae, groins, feet, ano-genital, inter- aud infra- 
mammary regions. In a qualitative sense, every degree of odorous- 
ness is noted, from that which is merely slightly agreeable or offen- 
sive, to the most intolerable stench. When complicated by a seborrhoea 
in situations where the parts are not only warm, moist, and covered 
by clothing, but also subjected to friction aud long uncleansed, the 
most intolerable and nauseous fetor is perceived. 

Sweat may be effused in a normal condition, upou and within the 
articles of clothing worn, and subsequently generate a stench by 
chemical changes both in the clothing, and the fluid by which that 



CHROMIDROSIS. 103 

clothing is saturated. This should never be forgotten in the prac- 
tical management of any case. 

Treatment. — The treatment of bromidrosis is, in general, that of 
hyperidrosis already described. Thin 1 has successfully employed 
stockings and cork soles dried thoroughly, after saturation for hours 
in a jar containing a solution of boric acid. The efficacy of this, 
he ascribes to the fact that the odor is the result of the development 
in the secretions of the bacterium foetidum. An ointment is also em- 
ployed by him for similar purposes, produced by making a solution 
of the acid in glycerine, and incorporating it with a fatty basis of 
white wax and almond oil, making thus a " glycerated cream of boric 
acid." Armingaud, of the French Academy, has reported excellent 
results following the subcutaneous injection of three grains (0.20) of 
the nitrate of pilocarpine, eight of which operations were successful 
in reducing the abnormal sweating fetor. Clement Hawkins 2 finely 
triturates fifteen grains (1.) of the red oxide of lead, and to this adds 
gradually one ounce (32.) of Goulard's extract. This is used as a 
lotion following a nightly foot-bath containing an ounce (32.) of alum. 

Fox (1. c.) advises a one per cent, solution of chloral, or potassium 
permanganate as a topical application. 

Internally the sodium salicylate has been employed with success in 
five grain (0.33) doses. 

Ohromidrosis. 

Gr. xptifia, color ; vdup, water. 

By this terra is indicated the condition in which effused sweat exhibits an 
abnormal color, yellowish, reddish, greenish, or blackish. The term Cyan- 
hidrosis has been employed to indicate blue sweating. 

In these cases there has been usually a copious secretion of fluid. 
Authors have variously attributed the color to the presence of com- 
pounds of phosphorus, iron, cyanogen, indican, Prussian blue, 
hsematin, chromogen, and even to parasitic vegetations upon the 
surface. Women, much more often than men, exhibit the free deposit 
of pigment upon the skin, and, in view of the admitted rarity of 
chromiclrosis, the suspicion arises that in some of the cases reported, 
there was free pigmentation of the surface by which the fluid exuded 
was immediately stained or colored. Duhring reports a single case 
of red sweating in a vigorous male patient. Usually, however, the 
phenomena occur in persons who betray some evidence of impairment 
of other organs than the skin, or who are debilitated in general 
health, thus furnishing an indication for their treatment. 

Babesiu, 3 of Pesth, reports some interesting cases of this disorder, 
which appear to have been produced by the presence of bacteria. In 
four patients, three of them women, there was considerable pruritus 
with pale red to blood-red sweat ; in one, the skin, and hairs were 

1 Practitioner, December, 1881, p. 2101. 

2 Brit. Med. Journ., May 7, 1881. 3 Lancet, 1862. 



104 DISEASES OF THE SKIN. 

reddened. The axillae were the source of this colored perspiration. 
In all the cases microscopical examination revealed similar changes. 

The hairs of" the axilla' were thin, pale-red, brittle : and surrounded 
with a colloid-looking, rusty, or bright-red sheath, in places of con- 
siderable thickness and having a rough surface. It consisted of red 
masses, presenting a radiating striation, more or less confluent, appa- 
rently proceeding from fibres of the cortex of the hair, or from some 
broken part of its Burface. The radiating striation was found to he 
dm' to the aggregation of round or ovoid bacteria, scarcely a micro- 
millimetre in diameter, which were united in zoogloea masses by a 
reddish, intermediate substance. Xodular swellings on the hair were 
produced by the infiltration of the organism between the separated 
fibrils. The roots of the hair were free from bacteria. The red tint 
of the sweat was found to depend upon numerous roundish masses 
of zoogloea. 

T. ( '. Fox 1 also has reported two eases in which a deep bluish- 
black pigment was exuded upon the skin of the circum-orbital 
region. The amorphous granules were found insoluble in almost all 
hot or cold reagent.-, but displayed a deep blue color when moistened 
with glycerine, and a purplish hue when dissolved in hot sulphuric 
acid. 

The hypothesis, that certain cases described as chromidrosis are 
really instances of mechanical washing of pigment to the surface in 
the profuse sweating of the debilitated, is strengthened by the phe- 
nomena of simultaneous hair coloration. Thus, Prentiss 2 reports the 
case of a young woman affected with acute cystitis and passing puru- 
lent urine, wdiose hair, under the influence of profuse sweating in- 
duced by the action of pilocarpine, changed speedily from a light 
blond to a nearly jet-black hue. At the meeting of the American 
Dermatological Association, in 1881, the author exhibited hairs of a 
middle-aged man which had changed in a night from a grayish-white 
to a greenish and yellowish-brown hue; and in commenting upon 
these, Dr. White, of Boston, stated that he had observed several 
similar cases of hair coloration as the result of profuse sweats. 

In the year 1884, this same observer reported to the Association 
the case of a workman in a sugar refinery whose sweat from the left 
side of the body was of a bright yellow color for several months, and 
where, though -ought for, no bacteria were discovered. 

In a case observed by Bergmann, a mycelium was recognized 
which was subsequently cultivated on paste. Eberth has recognized 
bacteria in both normal and yellow sweat. 

Le Roy de Mericourt, first to name this disorder, 3 has also 4 de- 
scribed a case of rosy sweating in an infant. 

Fereol believes that in these cases there is actually an absence of 
sweat and prefers to call the disorder chromocrinia. 

In all eases, before accepting statements of patients as to the exi.-t- 

i Med. Press and Circular, Jan. 1, 1881. - Phila. Med. Tines, July 2, 1881. 

Arch. gen. de Med., Nov. 1857. * La France Medic, 1884. 



URIDROSIS. 105 

ence of symptoms of this character, it is needful to eliminate the 
possibilities of deceit and accident. Coloring matters received upon 
the hands may be, either in wilfulness or ignorance, transferred to the 
surface of the body. 

The treatment is that of the general condition of the patient ex- 
hibiting these symptoms. 

Uridrosis. 

Gr. ovpov, urine ; vdup, water. 

While a small amount of urea is to be recognized in normal sweat,, 
it may, under peculiar conditions, be increased, and, together with 
urinary salts, deposited upon the skin suria.ce after evaporation of the 
exuded fluid. Such symptoms have usually occurred either as the 
result of grave constitutional affections, such as cholera, or of organic 
renal disease, accompanied by anaemia ; or of the ingestion of jabo- 
randi. In a few cases, the symptoms have been presented in indi- 
viduals who were apparently in good health. The salts of the urine 
appeared upon the skins of these patients in the form of minute 
lamellae, or a fine powder of whitish color and crystalline aspect. In 
some cases reported the symptoms have been noted to precede by a 
few days a fatal issue. 

The constantly adjusted equilibrium between the sweat and the 
urinary excretion would explain, for cases of a mild type, temporary 
augmentation in the urea formed in the sweat of unusually free dia- 
phoresis. Geber supposes that decomposition products, such as the 
carbonate of ammonium, possibly aided by the volatile fatty acids,, 
may in part account for these conditions. 

Dysidrosis. — Under the names Dysidrosis and Cheiro-pom- 
pholyx, Tilbury Fox and Hutchinson, of London, respectively,, 
described cases in which deeply imbedded, pin-head sized, acuminate,, 
primarily translucent vesicles occur upon the palmar and inter-digital 
surfaces. Both in consequence of coalescence and increase in size, 
bullae may subsequently form an inch or more in height, filled with an 
alkaline or slightly acid fluid supposed to be sweat, Partial absorp- 
tion occurs if the lesions be undisturbed, after which desquamation 
ensues from a reddened non-discharging surface. The cuticle about 
the lesions may be soddeu, and macerated, or reddened ; it is usually 
painful and swollen. There is often produced a sensation of prick- 
ing, burning, or itching. The eruption is most commonly discovered 
upon the hands, and less frequently upon the feet ; though other por- 
tions of the body may be involved. 

No little controversy has arisen respecting the exact nature of this 
disease, Fox and Crocker, on the one hand, 1 claiming a sudoral 
origin for the malady ; while llobinson 2 concludes, from a careful 

1 The Histology of Dysidrosis, London, 1878, from Trans, of the Path. Soc. of London, vol. xxix., 
1878. 

2 Pompholyx, Arch, of Derm., 1877, vol. iii. No. 4, p 289. 



106 DISEASES OF THE SKIN. 

study of a single case, that "everything points against its being an 
affectioD of the sweat-glands." In his treatise this author Dames the 
disorder pompholyx, classes it where it properly belongs among the 
exudative affections of the skin, and describes it as a neurosis. The 
evidence on this point is striking. Fox says: "I never knew any 
patient who had this disease .... well." He describes a 
condition of well-marked cachexia in all his cases. Robinson's 
patient was sickly for years, had twice suffered from fracture of the 
femur, had lost three of six children, and was " depressed." The 
severest lesions exhibited by patients observed by the author, were 
those in a woman who had chronic enlargement of the spleen ; and 
in a man who was profoundly cachectic, suffered from night sweats, 
had a sallow hue of the skin, aud subsequently died paraplegic. 

Geber, however, in studying two cases of this kind iu middle-aged 
men coming under his observation, believed that the lesions were not 
pemphigoid. 

ELematidrosis, or bloody sweat, reported as observed by several 
authors (Foot, Fbers, Parrot), is a name applied to conditions in 
which blood has been seen to exude from an unbroken skin. The 
phenomena described under this title belong properly to the en- 
semble of symptoms called haemophilia, and may iu some cases be 
due to direct transudation of red and white blood-corpuscles aud 
fibrine into the inter-epithelial spaces traversed by the sweat-pores. 
Geber points to the neuralgic, hypersesthetic, pruritic, or emotional 
symptoms that are usual precursors to the flow of pale or bright red 
blood. The fact that the patients thus affected are mostly women, 
hysterical, dysmenorrhoeic, or near the puberal epoch, also throws 
light upon these cases. In many of them petechia;, or signs of 
hemorrhage into other tissues of the body, were observed. 

In the effort to eliminate certain substances, accidentally or other- 
wise introduced into the system, the sweat may possibly become 
charged with iodine, turpentine, tar, arsenic, phosphorus, and other 
articles. After the ingestion of the last-named substance, the secre- 
tion is said to have occasionally become luminous. Doubtless 
several of the eruptions described in the chapter on dermatitis 
medicamentosa are due to a similar eliminative effort, especially 
those accompanied by excessive sweating and the production of 
vesiculation. 

With equal reason it may be inferred that the sweat is at times 
charged with excrementitious and other products of the body ; as, 
for example, the principles of the bile. During the late civil war the 
author observed several patients affected with yellow fever whose skins 
exhibited the characteristic hue of that disease, and whose sweat was 
similarly colored. The so-called " Galactidrosis," from supposed 
metastasis of milk, does not occur. Cases thus described have been 
instances of pathological sweat in the puerperal state. 



SEBORRHEA. 107 



2. Of the Sebaceous Glands. 

The disorders named in this group all depend upon functional 
■derangements of the sebaceous glands, whose office, it will be remem- 
bered, is the supply in part of the physiological unguent of the 
skin and hairs. What proportional part of this process is borne by 
the coil-glands, and what part by the sebaceous glands, it is difficult 
to determine. It should be remembered that the varieties of acne, 
which is a disorder of the sebaceous glands and their periglandular 
environment, are described in Class II., among the inflammations of 
the skin. 

Seborrhoea. 

Lat. sebum, tallow ; Gr. peu, to flow. 

Seborrhoea is a functional disorder of the sebaceous glands, exhibited in an 
abnormal condition of the secretion as it collects upon the surface of the skin. 
This disorder is also termed Steatorrhoea, Acne Sebacea, and Dandruff. 

Symptoms. — Seborrhoea occurs in two forms, according to the con- 
dition of the excreted product. These are known as seborrhoea 
sicca and seborrhoea oleosa. The two forms are recognized clinically 
as of separate occurrence ; and also as existing occasionally at the 
same time in one person. Either form of the disease may be limited 
to certain sites of preference, or be generalized so as to extend over 
all portions of the body provided with sebaceous glands. The most 
•common seats of the disease are : the scalp, the face, the genital 
region, the dorsum of the body between the scapulas, and the anterior 
surface of the chest. It appears at all periods of life, and in both 
sexes. As the sebaceous glands are mainly appendages of the hair- 
follicles, the lesions of the disease differ somewhat, according as they 
occur in the regions covered with long or lanugo hairs. In the same 
proportion, a difference exists in the career of the disease. At times 
it is a trivial and short-lived affection ; at others it is persistent and 
intractable, lasting for years, and possibly for a lifetime. The indi- 
viduals thus affected exhibit a difference also with respect to the 
general condition of their health. Some are anaemic, chlorotic, or 
asthenic ; some are of the sanguine temperament, fleshy, red-faced, 
and thick-skinned ; others again are absolutely healthy, so far as 
can be discovered, except for the local sebaceous disorder. This last 
fact is one of some significance. One may see exaggerated types of 
seborrhoea in vigorous men who have worn for one month merely, a 
skullcap, to which was fastened an apparatus for relief of fracture 
of the lower jaw. 

The skin affected with a seborrhoea is usually anaemic, and either 
dry or humid. In such cases the subjective sensations are either 
slight and limited to a moderate degree of itching, of which the 
patient does not complain until he is questioned upon the subject, 



108 DISEASES OF THE SKIN. 

or altogether wanting. At other times the glands, or periglandular 
tissues, are affected with a mild form of inflammation, and then the 
involved surface may be reddened and become the seat of a consider- 
able pruritus. 

Seborrhoea Sicca (or Squamosa) 

is the most common of all forms of the disease, and occurs upon 
both the hairy and non-hairy portions of the integument. In the 
former situation, where it is vulgarly known as "dandruff," it is 
called — 

Seborrhcea Capillitii, in consequence of its limitation to the 
hairy scalp. In its ordinary manifestations, the affection is recog- 
nized in the adult, by the formation in this region, of greasy, 
whitish or yellowish pellicles of dried sebaceous matter, which may 
be freely shed from the surface and cover the shoulders of the indi- 
vidual whose scalp is involved. At other times these fatty plates are 
more or less adherent to the scalp surface, or piled up in lamina?, 
one upon another. These may closely mat the hairs together, per- 
ceptibly near the exit of the latter from their follicles ; or be abun- 
dantly disseminated through the mass of the hairs, some of which 
penetrate a flattened greasy scale, as a twig might be passed through 
the centre of a leaf. In consequence of their deprivation of unguent, 
the hairs to which the affected glands are accessory, become dry and 
lustreless, and fall from their follicles. If the process be not 
arrested, atrophy of the hair- follicle ensues, and the resulting alopecia 
is permanent. 

Fortunately, the seborrhoea is usually symmetrical, and, corre- 
spondingly, the baldness which it occasions. The disfigurement 
then resulting is of the character of symmetrical senile alopecia, and 
is chiefly annoying as the loss of hair is premature. When the loss is 
asymmetrical, which is decidedly the exception, the disfigurement is- 
greater. 

The affection may be circumscribed, and in conspicuously selected 
patches where thin, mealy, grayish, or whitish scales cover the patch : 
or thick yellowish masses may paste the hairs firmly to the surface 
of the scalp. The disease may also extend over the entire surface 
of the scalp uniformly ; or, as is frequently noticed, fringe the brow 
at the line of the hairs, and then extend chiefly over the vertex, 
being conspicuous at the line where the hairs are parted from vertex 
to brow. 

Beneath the scales or crusts of dried sebum the scalp is usually 
lustreless aud of a slate-gray color. As the disease does certainly 
occur at times in types intermediate between functional and inflam- 
matory forms, the adjacent tissues may present a hypersemic or 
even exudative feature, with true epithelial desquamation and con- 
siderable itching. One group of cases, assignable to this class, 
deserves attention. In them there is a tolerably well-diffused sebor- 
rhoea sicca of the scalp, aud, here and there, irregularly distributed 



SEBOREHGEA. 109 

•over the surface, are filbert-sized, generally circular, dark reddish 
patches, covered with a moist secretion or a friable, granular, reddish 
and yellowish crust. These are scalp excoriations produced by the 
finger-nail. They are most common in "nervous" patients, who 
cannot resist forcibly digging the scalp on slight provocation. 

Occurring in infancy, the disease is well known as " milk crust," 
or as crusta lactea. This may be merely persistence of the dried 
vernix caseosa about the vertex in the newly born, or it may occur 
in scalps which have been perfectly cleansed after birth. The crust 
differs somewhat in color with the tint of the child's complexion ; 
and may vary from a light yellow to a dark brown. It may be 
thick, greasy, and mat the hairs together ; or be thin, dry, and 
friable. It is a frequent complication of the eczematous disorders 
•of this region, and, as a consequence, more often in the adult, every 
variety of hyperemia and inflammation may affect the tissue beneath 
the crust. In infants and children, however, the resulting alopecia 
is never permanent, as the rapidly growing follicles hasten to repro- 
duce the hair. The disease is also neither contagious nor followed 
by cicatrices, points upon which mothers are usually solicitous. 

The regions of the brow, the surface covered by the beard of 
the male, and the pubic hairs may be involved in the disease. 

Seborrhoea of the non-hairy portions of the body may exist upon 
the face (forehead, cheeks, chin, and nose), trunk, and genitals. 

Seboebhcea Faciei is characterized chiefly by the accumulation 
of thick, dirty-yellowish, and even yellowish-black, accumulations 
of sebaceous matter, often adherent to the surface and disfiguring 
the features by the artificial mask produced. This is exceedingly 
conspicuous about the nose, where the disease is at time symmetri- 
cally disposed. There was lately exhibited to the medical class at the 
author's clinic, a young woman with a complete cast, covering the nose 
uniformly from root to alas, composed of only yellowish-gray sebum. 
Such masses once removed, the skin beneath is generally found to be 
pallid or slightly reddened, with the orifices of the sebaceous ducts 
patulous ; while the under surface of the separated crust is seen to 
project downward in corresponding delicate prolongations, which 
Kaposi compares to stalactites. The crusts are rapidly reformed 
when the disease is not arrested. They are found in the furrows on 
either side of the nostrils, on the brows, the cheeks, and the pavilion 
of the pinna of the ear. They are most common at the puberal 
epoch in both sexs, when the sebaceous glands of the skin undoubt- 
edly sympathize with the changes occurring in the beginning of the 
sexual life. 

Seboeehcea Teunci is chiefly seen about the clavicles, scapulas, 
sternum, and umbilicus. Its features are less pronounced than those 
of some other localities, probably because the friction by the clothing 
•even in persons who neglect the care of their skins, serves to stimu- 



110 DISEASES OF THE SKIX. 

late to a moderate degree the sebaceous glands of those regions. The 

disease occurs here in circumscribed or, more frequently, illy defined 
patches which by confluence may describe irregularly reticulated 
figures of reddish tint, when, as is usually the case, the few loosened 
fatty plate- have been removed by friction. According to Duhring, 
who has carefully studied these features, the chest patches are circular, 
pale reddish in color, defined in outline, separate or associated in large 
groups, and covered with withered, greasy, grayish-yellow pellicles, 
the eruption here much resembling ringworm of the body. About 
the umbilicus, the fatty matters are remarkable for their tendency to 
speedy decomposition, with the production of an exceedingly fetid 
odor, which may prove to be the source of a mild grade of inflamma- 
tion. In the latter event, a reddish halo surrounds the umbilical 
depression, which may be the source of a thin, sero-purulent discharge. 

Seborrhcea Genitalium is usually located in men in the sulcus 
behind the corona glandis, though in individuals with a tight or 
redundant prepuce it may be more extended. In women, the 
accumulation occurs about the clitoris and vestibulum, though the 
external labia may be covered with the secretion in various degrees 
of fluidity. The smegma preputii supplied by the glands of Tyson 
may be thus the source of trouble either by its retention, or secretion 
in abnormal quantity or quality. In either event the tendency, as in 
umbilical seborrhcea, is to decomposition, fetid odor, and subsequent 
irritation, which may provoke inflammation of severe grade. The 
retention of this smegma beneath a tight prepuce in the male 
may provoke a long list of reflex symptoms, such as incoordination 
of movements in the lower extremities, nocturnal enuresis and pollu- 
tions, hernia, and irritability of the testis. In some cases the secre- 
tion forms a ring as hard as the rind of cheese encircling the glans. 
It should be remembered that the young of both sexes as well as 
adults are liable to be thus affected ; and that in young female chil- 
dren these symptoms may have a medico-legal interest in connection 
with suspicion of criminal attempts. 

Seborrhcea Generalis, affecting the entire surface of the body, 
is an exceedingly rare disorder. It has been described by authors as 
Ichthyosis Sebacea, Cutis Testacea, and Pityriasis Tabescentium. In 
the infant, the skin is universally spread with a greasy layer, rapidly 
renewed after removal, beneath which the skin seems to be varnished 
in reddish-brown shades. The consequent stiffening of the integu- 
ment produces painful fissures, inability to take the nipple, and con- 
sequent marasmus. In adults, there is noticed the same marasmus ; 
with greenish to blackish crusts covering the trunk and extremities, 
and desquamation of lamella? of the sebaceous accumulation, corre- 
sponding, for the most part, to regions of the skin mapped out by its 
normal furrows and folds. 



SEBORRHCEA. Ill 

Seborrhcea Oleosa 

is in its pronounced features rarer than seborrhoea sicca ; but to a less 
distinct degree is a condition sufficiently common in many forms of the 
disease. Here the sebaceous secretion is poured out as an oily fluid 
upon the surface both of the hairy and so-called non-hairy parts of 
the skin. In the former situation, both iu adults and infants, the free 
oily substance is seen to cover as a coating both skin and hairs, and, 
especially in bald adults, to produce a glistening and shining appear- 
ance of the scalp. It often concretes into masses which are described 
above as the crusts of seborrhoea sicca. The same greasy layer can 
be seen in the non-hairy portions of the skin, especially about the 
nose, forehead, and cheeks. Free drops of oil can be occasionally 
wiped from such surfaces with a handkerchief. The ducts of the 
sebaceous follicles are here either patulous or plugged with come- 
dones; the surface may be reddened or pallid, but is usually cold to 
the touch. The oily substance serves to entrap particles of dust, soot, 
etc., floating in the air, and often thus a peculiarly dirty or even 
blackish hue of the face is produced. Some of the forms of seborrhoea 
described above in connection with the umbilicus and genitalia, are 
of this variety. In the negro, where the sebaceous glands are usually 
well developed and active, the oily forms of seborrhoea are common ;. 
and the flux, at times, almost physiological. Even in the absence of 
their frequent anointing with palm-oil, one can see the naked blacks 
in Africa with exposed skins shining from exuded grease. 

Etiology. — Seborrhoea may be due to local or general causes. This 
is a point which should be clearly understood, as Hebra, with his 
superb powers of observation, noticed that the majority of his cases 
occurred in young male and female subjects affected with chlorosis or 
conditions analogous to that state. It is a clinical fact of ready veri- 
fication ; but it is clear that many cases are essentially of local origin ; 
and, as before indicated, a seborrhoea can be artificially produced in 
a healthy individual in the course of a few weeks by very simple 
local measures without interference with the general economy. 
Women with long hair are usually disposed to take special care of 
the scalp, upon which it grows. Men with short hair are more apt 
to attend chiefly to its disposition upon the head, and to neglect the 
care of the scalp. For the seborrhoea sicca of the hairy parts, neglect 
of the scalp is a frequent cause ; for the same disease of the non-hairy 
portions of the skin, in by far the greater number of all cases, chlo- 
rosis, struma, malnutrition, obstinate constipation, disorders of diges- 
tion and menstruation, and sedentary habits of life, are unquestion- 
ably responsible. The exanthematous and other fevers are often 
followed by asthenic states in which the same condition prevails. 
Hebra has pointed out the fact that the sebum of individuals who 
have fatty livers from chronic alcoholism, is peculiarly fluid and 
oily; and it will be observed that few of all the disorders of the 



112 DISEASES OF THE SKIN. 

sebaceous glands characterized by inspissation of the secretion occur 
in such persons. 

Pathology. — It will be remembered that the sebaceous secretion is 
produced in consequence of a fatty transformation of the epithelia 

lining the acini of the sebaceous glands; it is, therefore, directly de- 
rived from the living- matter of the protoplasmic elements of the rete. 
A seborrhoea is, therefore, strictly speaking-, a catarrh of the epi- 
dermis; and the name is in this connection properly used, since most 
of the so-called catarrhs of the skin are in reality not such, the effused 
fluids being furnished by the bloodvessels. Typical forms of sebor- 
rhcea are strictly anomalies of secretion only, unaccompauied by in- 
flammatory processes in either the glands or periglandular tissues. 
While other exceptional forms are without question thus complicated, 
the variations in the sebaceous product as to quantity, inspissation, 
fluidity, tendency to rapid decomposition and exhalation of fetid 
odors, may be due to variability in the transformation of the epithelia 
into fat under the influence of the trophic nerves, but this is a matter 
of conjecture. It is certain that these conditions are largely under 
the influence of external agents, such as friction, temperature, and air 
currents. In many cases the product of the disorder is composed, for 
the greater part, of epithelial masses mingled with a relatively small 
quantity of sebum, thus justifying further the view explained above 
regarding its catarrhal nature. 

The unguents naturally found in excess upon the body or parts of 
it, such as the vernix caseosa, are, of course, physiological in character. 

Diagnosis. — Seborrhoea is to be distinguished from : 

Eczema. — The objective points of difference between eczema and 
seborrhoea depend upon the inflammatory character of the first named 
disease, easily recognized, whether upon the face or scalp, by the 
reddened, infiltrated, or discharging skin, and the considerable degree 
of itching which it occasions. In squamous eczema, the scales are 
rarely so abundant as to be shed freely from the surface, and are not 
greasy. It should be remembered, however, that the two diseases 
may and do coexist. Eczema of the scalp in infants is especially apt 
to be accompanied by a seborrhoea, a fact which clearly shows that 
the technical distinctions between many diseases, useful though they 
be for analytical study, are not always capable of clinical demonstra- 
tion. 

Ichthyosis. — This is a congenital disease, usually involving the 
entire surface of the body, while seborrhoea is generally acquired, 
and rarely universal. The distinction between ichthyosis and the 
rare generalized forms of seborrhoea, described above, might involve 
a difficulty. But in the latter, the greasy charactei of the crusts, 
their color, and the marasmic condition of the subject of the disease, 
would sufficiently distinguish the two disorders. 

Impetigo and Impetigo Contagiosa. — Here the only possibility 
of error would originate in the discovery of either of the two diseases 



SEBORRHEA. 118 

named, in the stage of crusting, especially upon the scalp. But both 
are acute disorders, with crusts much bulkier than the sebaceous 
matters formed in seborrhoea, and beneath such crusts the integument 
is reddened and evidently the seat of an exudation. 

Keratosis Pilaris. — In this disease, also, there is a chronic 
accumulation of matters, partly sebaceous, on the hairy and non-hairy 
portions of the skin. But, unlike seborrhoea, the sebo-epithelial 
heaps are here aggregated in pin-head sized masses about the hair- 
follicles only, and never accumulate in such quantities as to paste 
the hairs to the surface. The disease is also most common on the 
extensor surfaces of the extremities. 

Lupus Erythematosus. — Hebra, in 1845, described a Seborrhoea 
Congestiva, which it would be indeed difficult to distinguish from 
lupus erythematosus, as the two are practically identical. Typical 
cases of the two diseases are widely different and readily distinguished ; 
the atypical forms might lead to confusion. But lupus erythematosus, 
though occurring on the face, is rare on the scalp ; it is accompanied 
by infiltration and the production of a new growth ; and is followed 
by a characteristic scar. Its lesions are darker red than the conges- 
tive patches beneath certain seborrhoeas of the non-hairy parts. The 
scales of lupus are tenacious and dry, and require scraping for 
their removal; those of seborrhoea are readily detached, greasy, and 
often cover the shoulders of the patient. The contour of the sebor- 
rhoeic patch is ill defined, while that of lupus is very distinct, excep- 
tion being made of the mask-like crusts seen in certain of the facial 
seborrhoeas, when the greasy character of the layer is very evident. 
Lastly, seborrhoea is a disease of puberty chiefly, while lupus erythem- 
atosus is likely to be first seen in the earlier years of childhood, 
when facial seborrhoea is rare. 

Psoriasis. — Psoriasis of the scalp may resemble seborrhoea sicca. 
But the latter is rarely developed in such a universal exanthem as is 
frequent in the former. Few doubtful cases will come under obser- 
vation, in which a psoriasic patch on the elbow, knee, leg, or sacrum, 
will not point to the nature of the disease. The scales of psoriasis 
are lustrous, larger, and not greasy, unless fatty applications have 
been made to soften them ; and they cover, moreover, a reddened and 
exuding patch of integument. Psoriasis of the scalp and face prefers 
the areas of the forehead adjacent to the hairs of the scalp, and rarely 
departs boldly to the nose and the furrows beside the nostrils, favorite 
sites of a seborrhoea. 

Syphilis. — Some forms of the pustular syphilodermata located 
upon the scalp and face, if observed only in the stage of crusting, 
might be confounded with seborrhoea. Here the history of the case, 
the discovery of other signs of syphilis (adenopathy, mucous patches, 
etc.), and the puriform character of the secretion beneath the crust, 



114 DISEASES OF THE SKIX. 

should point to the identity of the disease. In syphilitic crusts about 
the angles of the nostrils, there is often a peculiar reddish-brown tint 
of the skin at the edge of the patch, the so-called "copper" color, 
which is significant. ( Irusts of the hairy scalp in syphilis are very 
often accompanied by post-cervical adenopathy, and especially by in- 
durated enlargement of the occipital glands. 

Tinea Circinata and Tinea Tonsurans. — In ringworm of 

the hairy parts, as also of the body, the microscopical discovery of 
the parasite will always point to the nature of the disease. Upon the 
seal]), the affected patches are seldom as diffuse as in seborrhoea; are 
usually circular; are often accompanied by fragility of the hairs; and, 
in the latter case, the discovery of stumps of hairs is significant. 
There is also a history of contagion and absence of the greasy condi- 
tions of the .-eales characteristic of seborrhoea. 

Treatment. — The internal treatment of seborrhoea is often of the 
highest importance. The preparations most often indicated are: Iron 
in anremic young women; cathartics in sluggishness of the bowels; 
aud cod-liver oil when there is impairment of nutrition. Duhring 
recommends the sulphide of calcium iu doses of from one-tenth 
(0.0066) to one-fifth (0.0133) of a grain. Arsenic, employed iu the 
manner suggested by Sir Erasmus Wilson, is praised by Hebra : 

R. Vin. ferri foj^s; 50 



Syrup, simpl. ) 

Liq. potass, arsenit. j 



f3ij ; 8 



128 M. 



Aq. destill. fgij; 60 M. 

S. A teaspoonful to be taken three times daily with the meal. 

Iu many cases, the acid iron mixture of Startin, or some modifi- 
cation of it, admirably meets the indications present : 

R. Magnes. sulph. ,fij ; 64] 

Ferri sulphat. 9>s-BJ ; 0.66-1.33 

Acid, sulph. dilut. f3ij-foiv; 8-16 

Infus. quassia? adf^iv; 128 

S. A teaspoonful in water, through a tube, after eating. 

The preparations of malt aud maltine, uow largely employed in 
the treatment of wasting diseases, will be found available in cases 
where the cod-liver oil canuot be well taken. Lastly, the bitter 
tonics may be needed. Throughout the treatment, the physician 
should insure a careful observance of the laws of hygiene. Sunlight, 
nutritious food, and open air exercise are not to be disregarded. In 
the large cities of this country, many young women of indolent 
habits are greatly benefited by sending them to the riding-schools for 
an hour's equitation daily. 

The indications to be met by local treatment in seborrhoea are: 
first, the removal of the crusts and the fatty matters accumulated 
upon the surface; second, the restoration of the deranged function 
of the glands. 



SEBORRHOEA. 115 

Upon the scalp, it is always well to warn patients, especially if the 
disorder is aggravated, and occurs in young women with apparently 
luxuriant tresses, that a coDsiderable loss of hair will result. Many of 
the filaments are so impoverished by the chronic course of the disease, 
and so loosened in their follicles, that a complete cleansing of the 
scalp surface will bring them away in quantities sufficient to threaten 
a speedy baldness ; aud it is not rarely the case that patients attribute 
this to the treatment rather than to the disease. The fatty accumula- 
tions are first to be soaked in some oily fluid to facilitate their 
removal ; and for this purpose olive oil, cod-liver oil, vaseline, cold 
cream, almond oil, glycerine, or lard is usually employed. The 
article selected should be used in excess, and in quantity sufficient to 
permeate all crusts. It may be poured over or rubbed into the scalp 
several times in the twenty-four hours ; and at night a flannel or 
other cap be worn to insure still further success. In the case of 
children and infants, considerable gentleness is required in thus 
treating the scalp, especially in the subsequent washings, lest the 
surface be irritated. In young women it is rarely necessary to cut 
the hairs. As soon as the soaking with oil is insured, the crusts are 
to be removed by washing with soap and water, though when the 
accumulations are bulky, masses may be gently removed with fingers 
or comb. When the scalp is quite tender, ordinary toilet, or Sarg's 
glycerine soap, may be applied with warm water ; but it is usual, in 
the case of adults, to employ the spiritus saponis kalinus of Hebra, 
two ounces (64.) of green soap digested in one (32.) of alcohol, filtered 
and flavored with lavender or bergamot. The surface should be 
thoroughly sponged with the spirit, and then warm water added till 
the foam of the lather is abundantly produced over the scalp, when 
an excess of water is finally used to cleanse the part of both crusts, 
oil, and soap. The scalp and hairs are then thoroughly dried, and 
anointed with some bland, fatty substance, if the surface exposed is 
tender and irritable ; if not, with some stimulating pomade. 

The last-named precaution is an important one. However exten- 
sive the seborrhoeic crusts, it is possible to remove these completely 
by the measures described above, in every case ; and with the first 
experiment patients are often delighted. Their disappointment is 
correspondingly great when they discover that the seborrhoea is not 
yet at end, and that, in the course of a few days, the fatty plates are 
as freely as ever deposited on the scalp, disseminated through the 
hairs, and showered upon the shoulders. Some will even declare 
that the soapy applications aggravate the disorder by increasing the 
seborrhoea. It should, therefore, never be forgotten that, having got 
rid of the extraneous matters accumulated upon the surface, there is 
still to be remedied a functional disorder of the sebaceous glands of 
the part. 

In every case, then, after the use of the soap and water, which may 
be repeated as often as need be, daily, at intervals of several days, or 
once in the week, the scalp is to be thoroughly anointed. For this 
purpose olive oil, cod-liver oil properly scented, almond oil, vaseline, 



116 DISEASES OF THE SKIN. 

or glycerine and water, may be used. In the course of a few days, 

in most instances, a more stimulating plan of treatment may be 
adopted ; and, in that event, alcohol may be combined, for example, 
with the oil of' sweet almonds, half an ounee (10.) of the latter to five 
ounces (160.) of the former, to which half a drachm (2.) of carbolic 
acid may he added, the whole flavored with the oil of bergamot. 

A r an Harlingen recommends the oleum moringae nucis, or oil of 
benne, as a substitute for others, since it does not dry and elog, as do 
the latter. An ounce (32.) of this rubbed up with five grains (0.33) 
of powdered benzoin, and digested for three hours over a water-bath, 
with the addition of three drops of absolute alcohol, and filtered, 
furnishes an excellent basis for oily mixtures to be used on the scalp. 

Dr. Morison, 1 of Baltimore, has devised an ingenious instrument 
for the application of oily fluids to the seal]). The latter are retained 
in a small reservoir, to which is connected a comb with perforated 
teeth. Through the latter the article selected for medication of the 
scalp readily passes down to the surface between the hairs. 

In the place of oils after these ablutions the ointments are often 
used with more advantage. For this purpose the beuzoated oxide 
of zinc ointment, cold cream, or salves containing ten per cent, of 
tannin may be applied. 

In cases where milder effects are required, the seal]) may be washed 
in water containing such alkaline substances as borax, ammonia, and 
the carbonate of potassium. The popular prejudice against these 
articles is based upon the abuse of strong alkaline lotions in the 
hands of inexperienced persons. Such lotions may be readily tested 
by the tongue for the degree of softness required for the scalp. 
They should, in the management of all cases, be followed by an oiling 
or greasing of the surface. Women solicitous about their personal 
appearance are apt to object to such inunctions, preferring greatly 
the drier conditions of the scalp and hair, a prejudice often respon- 
sible for the disease in question. 

Veiel recommends the following formula : 

R. Extr. cinch, frig. par. ^j ; 1 

Bals. peruv. gtts. xv ; 1 

Cantharid. tinct. gtts. xxiv-3ss ; 1.5-2 

Succ. citri n\,xv ; l 

Ungt. poinat. 5Jss ; 50 M. 

S. To be rubbed into tbe scalp once or twice daily. 

The tars are useful in many obstinate cases. Tar soap may be 
employed in the washing; or the oleum rusci added in the strength 
of one to ten parts to the other salves recommended above. Ichthyol 
in ointment- of the strength of five to ten per cent., and resorcin in 
spirit lotions of ten grains (0.66) to the ounce (32.) have also proved 
efficacious. 

Repeated applications and patient care of the seal]) are necessary to 
secure complete relief in the case of a disease as essentially chronic 
as seborrhoea. At times the local treatment may be changed with 

1 Maryland Med. Journ., January, 1885. 



SEBOKRHffiA. 117 

advantage. Sulphur enjoys a high reputation in the treatment of all 
sebaceous gland disorders ; and in the form of an ointment, one to two 
drachms (4.-8.) to the ounce (32.) of cold cream, it is often of service. 
The author has used with success the hypochlorite of sulphur, which 
has lately come into our markets from the English laboratories. But 
it is open to objection on account of its odor, which can scarcely be 
disguised. Beside these, the tinctures of cantharides, capsicum, and 
nux vomica are frequently incorporated with advantage into lotions 
and pomades for use upon the scalp. Most of the latter can be made 
sufficiently fluent for use in this situation, by adding a drachm (4.) or 
two (8.) of glycerine to the ounce (32.) of lard or cold cream. The 
alterative effect of the mercurials is also as evident here as in many 
other cutaneous disorders. At the head of the list, for this special 
purpose, stands the red oxide of mercury in the strength of from two 
to four grains (0.133-0.266) to the ounce (32.) of ointment; but the 
white precipitate, the ammoniated mercury, and calomel, in the pro- 
portion of five to ten grains (0.333-0.666) to the ounce (32.) may be 
often substituted for the former with advantage. Solutions of cor- 
rosive sublimate, in the strength of two to four grains (0.133-0.266) 
to the ounce (32.) of fluid, may prove of use in obstinate cases. Hil- 
lairet recommends a lotion containing from two to four fluidrachms 
(8.-16.) of sulphuric ether and two to four drachms (8.-16.) of borax 
dissolved in eight fluidounces (256.) of distilled water. 

Viguier advises the following lotion for use in seborrhoea of the 
scalp, in those cases more particularly where loss of hair is threatened : 



R. Santal. ess. 


) 






Eosar. ess. 


Y aa tt^v ; 




30 


Chimaphil. umbell. es 


S.J 






Pilocarpin. muriat. 


gr. vijss; 




50 


Spts. vin. rectif. 


liij; 


100 




Camphor, spts. ] 








Glycerin. > 


aa 3j gr. xv; 


5 




Cantharid. tinct. ) 








Dissolve the pilocarpine in 


the alcohol, and then add the other ingre- 


dients. 









The treatment described in outline above, may be used with 
success also for the relief of seborrhoea of the non-hairy portions of 
the body, especially the face. Here, it will be observed, the crusts 
have a singular tendency to re-form, and the most persistent care is 
necessary to secure permanent relief. Occasionally, after cleansing 
the surface by soap and spirit lotions, according to the indications of 
each case, it is of advantage to apply the ointment selected for subse- 
quent application, not only by gently smearing it on the part with the 
tips of the fingers (always the most effective method), but also by 
spreading it on a compress, which, for the night at least, may be fixed 
in contact with the part. 

Unna's lead-plaster mulls, used for this purpose in Germany, may 
be fairly well imitated by drawing strips of cheese-cloth through 
heated diachylon ointment and then smoothly smearing them w T ith 
the same material. 



118 DISEASES OF THE SKIN. 

When this tendency to reformation of the crust is abated, one or 
more of the dusting powder- may be at times employed with 

advantage for the purpose of protecting the skin or exercising upon 
it an astringent effect. 

The local treatment of seborrhoea of the genitals is somewhat 
different. Ointments rarely answer well in disorders of the mucous 
surfaces ; and the green soap is too irritating for similar employment. 
Here washing with a good toilet soap and warm water is sufficient 
for the purposes of cleanliness, and diluted lotions containing alcohol, 
in the form of whiskey, brandy, or aromatic wine, suffice to procure 
relief. These can be made astringent with tannin, alum, or the zinc 
sulphate, and, when there is pain or tenderness, opium can be added. 
In this form of the disease, as also in seborrheas of the umbilicus, 
carbolic acid or the chlorinated soda may be necessary to correct 
fetor. In the generalized varieties of the disease the surface is to be 
thoroughly anointed with oil. The body, especially that of infants, 
is to be swathed in flannel or other good non-conductor of heat ; and 
a roborant treatment directed to the general adynamia. 

In the grave forms of seborrhcea of infants described as keratosis 
sebacea, ichthyosis sebacea, etc., the body must be kept anointed with 
oils or fats. Artificial feeding is demanded by the condition of the 
mouth. 

Prof/noxi*. — In forming a prognosis in cases of seborrhcea, it must 
be remembered that the disease is frequently an obstinate one ; and 
the resulting loss of hair, if symmetrical, may be remediless. Much 
may be done in the way of saving that which is left. Facial sebor- 
rhoea is much more amenable to treatment ; and seborrhcea of the 
genitals and umbilicus is an entirely manageable disease. When 
the affection is generalized, the prognosis is in the highest degree 
unfavorable. 

Comedo. 

Lat. comedo, a spendthrift. 

Comedo is a disease in which an inspissated secretion, lodged in the excretory- 
ducts of the sebaceous glands, becomes visible upon the surface in yellowish- 
white or brownish-black points. 

Symptoms. — Comedones occur exclusively in the ducts of the 
sebaceous glands, and consist of a whitish fatty plug formed by the 
inspissation of the secretion of these glauds, one extremity of which 
i- visible at the surface when the plug is in situ. Occasionally they 
project to an appreciable distance above the general level of the 
integument ; but often the extremity of the plug is slightly depressed 
below that level. There may be but two or three upou the face, 
which is their most common seat; or the nose, forehead, cheeks, chin, 
the front and back of the neck, and the back of the trunk, aud the 
penis may be thickly studded with them. The visible extremity of 
the comedo varies in size from a needle-point to a pin-head. They 
are readily expressed from the follicles in which they are lodged, and 



comedo. liy 

when thus examined are seen to be whitish moulds of inspissated 
sebum, one to two Hues in length, the exposed extremities of which 
have become blackened by the dust and dirt entrapped at that point. 
In consequence of this suggestive appearance of the mass, the disease 
has been vulgarly known as " black heads" and " skin worms." The 
deformity produced in the face when these lesions exist there in large 
numbers, is strikingly conspicuous ; and it is for the relief of this 
chiefly, that the practitioner is consulted. The subjective symptoms 
awakened are of trifling moment. The disorder is essentially chronic 
in its course. Isolated comedones may be observed for years in one 
situation without apparent change or modification of any sort, and 
without producing the slightest local or constitutional derangement. 
Others appear, only to disappear under the influence of the usual 
hygienic regimen of the skin of the face. Others, again, serve to 
irritate the skin in which they are implanted, precisely as though 
they were foreign bodies ; and the sebaceous glands and peri-glandular 
tissues, with and without the operation of such cause, exhibit grades 
of hyperemia and inflammation. Comedones may occur as the sole 
lesions of the skin, even to the extent of very great multiplicity; or 
they may coexist with other diseases of the glands, chiefly acne. They 
may occur at any period of life, but, like seborrhoea, are most fre- 
quently observed at the puberal epoch in both sexes. According to 
Kaposi, the disease tends to disappear in women earlier than in men, 
in whose case it may be prolonged to the twentieth or thirtieth 
year. 

Crocker 1 has called attention to the occurrence of comedones in 
children, with a special tendency to grouping in places subjected to 
heat and moisture, and also to occurrence upon the hairy scalp. 

Occasionally a so-called " double " comedo is formed, a plug of 
inspissated sebum being expressed from the skin, each extremity of 
which is discolored. Whether this be due to a duplicity of efferent 
ducts in a single gland, or to an artificial or pathological connection 
between two adjacent glands, is not clear. 2 

Etiology. — Much has been written with reference to the improper 
care of the skin as a cause of comedo, the neglect of soap in washing 
the face, and the influence of the trades, as in the case of those who 
work in metals, dust, and tar. But observation shows that these are 
exceptional causes. Very obstinate and generalized lesions occur in 
the skin of intelligent youug men and women of the upper social 
classes, who regularly wash their faces with toilet soap, are rarely 
exposed to dust, and whose habits and recreations are of the most 
healthful character. On the other hand, observing the grimy faces 
of coal heavers, machinists, masons, and ink manufacturers, one is 
impressed with the singular rarity of the disease in such laborers. 
The cause of the constipation of the gland is unquestionably to be 
sought for elsewhere, in the most of cases. It is true that chlorotic 

1 Lancet, April 19, 1884. 

2 A. H Ohniann-Dumesnil : Journ. of Cutan. and Yen. Dis., February, 1886. 



120 DISEASES OF THE SKIN. 

young women, affected also with dyspepsia and torpor of the bowels, 
may exhibit the disease; and equally certain that many cases occur 
in peculiarly thick-skinned bruuettes, or men with a characteristic 
reddish-brown and greasy-looking complexion. But for all this, 

many such never suffer from comedones, while often a perfectly 
healthy, fair-skinned girl will be greatly mortified by the disfigure- 
menl of her lace. 

Fig. 29. 













■■ b 



a. 



Section of a comedo, a, excretory duct of a sebaceous gland filled with a comedo ; it contains also 
two small hairs with brush-like inferior extremities; into it opens a small hair-follicle, o, whose 
contained hair, d, after touching the opposite wall of the duct, curves downward at/. (After Kaposi.) 

In vet other patients there is unmistakable connection between this 
disorder and chlorosis, scrofulosis, dyspepsia, habitual constipation of 
the bowels, menstrual derangements, and cachexia. This connection 
is demonstrated by the remarkable improvement manifested in the 
untreated skin when improvement of the general health is assured. 

Pathology. — The mass termed the comedo is a collection of con- 
centrically packed epithelial plates mingled with masses of cholesterine, 
fragments of epithelia undergone fatty transformation, minute lanugo 
hairs, and, occasionally, upon the exterior, the aearus foUirulormn. 
This little mite, first detected by Henle, in the ceruminous glands, 
was bv Simon and others once thought to be the cause of the comedo, 



COMEDO. 121 

a view which is now abandoned by all dermatologists. The parasite, 
in persons upon whose skin it exists, can be detected in masses of 
commingled sebum and epithelial plates scraped from the free surface 
of the integument, as also upon the surface of those who do not 
exhibit any disorder of the sebaceous glands. The comedo plug is 
located either in the excretory duct of the sebaceous gland or in the 
pouch-shaped canal common to the sebaceous gland and the hair- 
follicle. It will be remembered that in the class of sebaceous glands 
chiefly involved in the comedo, the hair-follicle is rather an appendage 
to the former, the relation between the two, evident upon the scalp 
for example, being here reversed. According to Biesiadecki, the 
hair-follicle often forms here an obtuse or even a right angle with 
the duct of the gland, and the point of the hair being thus projected 
against the wall of the duct, is occasionally curved downward upon 
itself, exciting thus an irritation at the point of impact and subsequent 
multiplication of the protoplasmic elements lining the canal. Thus 
he explains the epithelial character of the outer envelope of the plug; 
the special occurrence of the disease at the puberal epoch, when, as is 
well known, there is an especially active growth of the hairs ; and, 
lastly, the frequent discovery of lanugo filaments in the expressed 
contents of the common excretory duct. 

Diagnosis. — The recognition of the disorder is attended with no 
difficulty, patients themselves being usually sufficiently observant to 
identify the affection, though frequently misled as to the character of 
the " skin worm." It is, as might be expected, a frequent coincident 
of acne ; its lesions, when commingled with those of the disease last 
named, being either in preponderance or so infrequent as scarcely to 
attract the attention of the patient. A condition somewhat resembling 
the comedo may be produced upon the face when tar, or ointments of 
mercury and sulphur are applied to it at the same time, the resulting 
black sulphuret appearing conspicuously at various points upon the 
skin, often at the orifices of the sebaceous glands. 

Curiously atypical cases, however, are occasionally observed, and 
these might confuse one unfamiliar with the singular variations dis- 
played in almost all sebaceous gland disorders. Thus Cauty 1 reports 
a remarkable case in a boy ten years of age, who was somewhat im- 
becile but well nourished. The upper part of the back, both shoulders, 
and the outside of both arms were covered with short bristles, of a 
clear, darkish brown-yellow color, and acuminated apices. These 
bristles were, at the edges of the group, gradually shortened from 
their full length of three thirty-seconds of an inch, until they joined 
the skin, which was at the junction raised into polygonal, flat disks, 
finally graduating to the sound integument of the hands, chest, and 
back. The feeling communicated to the hand on passing it over the 
shoulders was exactly similar to that of touching a coarse brush, and 
the bristles gave way under the touch, resuming an upright position 

1 Medical and Surgical Journal, March 4, 1882, p. 237. 



1-- DISEASES OF THE SKIN. 

afterward. There were a few pink maculae over the body, and con- 
siderable scaly thickening on and around the patellas. The bristles 
were expelled comedones, containing very few immature hairs and 

very little sel 1. drying up into a horny substance. They were 

firmly attached, requiring more force to remove them than to 'extract 
a well-rooted hair; and when removed they left a .-mall, central 
depression, surrounded by a circle of torn epithelium, which retained 
them in position. They averaged one hundred to the square inch, 
and had existed over three months. 

A somewhat similar ca.^e was exhibited by Dr. Warren, before the 
New York Dermatological Society, January 26, 1886, and described 
as keratosis follicularis. 

Treatment. — The internal treatment of the patient affected with 
comedo is largely that described in connection with the subject of 
seborrhoea. God-liver oil, iron, the bitter tonics, and preparations 
indicated by any special condition of the patient's health, are not to 
be omitted. Open-air exercise, bathing, and the avoidance of all 
medicinal and dietary articles which might tend to aggravate the 
disorder, are also imperative. 

Even aggravated cases of comedo are completely relieved by natural 
processes in the course of time. These processes are, however, slow, 
and may require years for their completion. The rarity of come- 
dones in middle life and advanced years sufficiently attests this 
fact. Presumably this natural cure i's due to the more vigorous 
growth of lanugo hairs with the increment of age, which thus push 
forward slowly to the surface the excrementitious mass, until it is 
gradually removed by ordinary friction and ablution. Absence of 
comedones from the scalp, where the hair is vigorous, is certainly a 
significant fact. 

Comedones are removed artificially by the aid of an extractor. The 
instrument formerly employed for this purpose was shaped like a 
watch-key, the cylinder of which had a smooth bore and bevelled 
extremity. This clumsy tool is far surpassed by the exceedingly 
convenient comedo-extractor designed by Unna and modified "by 
Piffard (see Fig. 27). Each end has a convex bowl-like surface, with 
apertures cut to gauge and the orifices slightly counter-sunk. It is pro- 
ductive of for less pain to the patient than other instruments, and can 
be wielded, on account of its long shank, with greater precision and 
ease by the physician. The surface to be operated upon is best previ- 
ously moistened by spraying it with a thymol and glycerine, or euca- 
lyptol and glycerine solution. Often a sharp-edged 'or well-rounded 
needle, firmly held in a needle-holder, may be advantageouslv em- 
ployed, alternately with the extractor, in opening certain follicles or 
somewhat loosening the plug of others. All of these instruments 
should be scrupulously disinfected before use. With the present 
knowledge had on the subject of transmission of disease, the danger 
of such manipulations as these with uncleansed instruments should 
never be overlooked. Wigglesworth suggests the performance of 



COMEDO. 123 

the operation at night; and there are good reasons for selecting the 
hour before retiring as the time for all vigorous topical applications 
to the face. Ointments then applied can be left in contact with the 
skin during the hours of sleep; aud the patient be at liberty to 
resume his usual vocation in the daytime with his face free from 
conspicuous evidence of local treatment. 

An ordinary watch-key, the thumb-nail, or a spatula may also, on 
occasion, be used in the extraction of comedones, which may be, if 
few, removed at one sitting, or, if numerous, on separate occasions. 
Repetition of the process is usually required by the reformation of the 
plugs. 

Once they are removed, the skin should be sponged and bathed 
with hot water, then thoroughly dried, and anointed with an ointment 
which may be medicated to suit the indications of each case. Sulphur, 
as in all the functional disorders of the sebaceous glands, enjoys here 
also the highest reputation. In the strength of one-half to one 
drachm (2.-4.) to the ounce (32.) of cold cream or vaseline, it may 
be applied as an ointment ; or as a lotion, in combination with spirits 
of wine, glycerine, etc. The author has frequently used with advantage 
the mild application suggested by Piffard in acne, equal parts of sub- 
limed sulphur, alcohol, compound tincture of lavender, glycerine, and 
camphor water. 

Mercurials are also of some advantage locally, and, as before indi- 
cated, should not be employed at the same time with preparations of 
sulphur. The use at night, especially in obstinate cases, of the white 
precipitate ointment, or one compounded of two grains (0.133) of the 
red oxide to the ounce (32.) of cold cream will often prove of benefit. 
One to two grains (0.066 to 0.133) of corrosive sublimate to the 
ounce (32.) of glycerine and rose-water may be substituted for the 
latter in coarser skins. 

When the extraction of the plug is not attempted nor permitted, 
something may yet be done to remove the inspissated mass. Repeated 
sponging every third night with one ounce (32.) of the green soap, 
digested in an equal quantity of Cologne water, will, at first certainly, 
seem to render the comedo more conspicuous, but will slowly operate 
to dissolve the sebaceous secretion. 

Unna has lately observed that the blackish discoloration of the 
comedo extends to a certain degree below the external extremity of 
the plug, a circumstance, in his opinion, militating against the dust 
and dirt theory, by which the hue of the comedo point has been ex- 
plained. He concludes that this is the result of pigmentation, such 
as that producing the coloration of the hair, nails, and skin in several 
other anomalous conditions. Having this in view, he prescribes an 
ointment containing four parts of kaolin, three of glycerine, and two 
of acetic acid, with or without the addition of a small quantity of 
ethereal oil. This is applied at night, the eyes being carefully closed, 
for a few nights in succession, when the black points of the lesions 
are removed, and the comedones then readily extracted. Citric or 
dilute hydrochloric acid is employed, with the same end in view. 



124 DISEASES OF THE SKIN. 

The author has employed this formula in about fifteen cases, with 
varying results. It cannot be considered as efficient in every form of 
comedo. 

Actors, actresses, and women of fashion will occasionally persist in 
using variously colored toilet powders while under treatment, the 
injurious ingredients of which are often the cause of the disease. The 
practitioner may then either refuse to be responsible for the care of 
the case; substitute a harmless for a noxious powder; or gently 
anoint the face after his treatment of it with a bland ointment, upon 
the surface of which the theatrical effects are subsequently produced. 
In such cases the use of soap and water with each dressing i> even 
more than usually imperative. 

Comedones of the penis need not he treated. This injunction is 
suggested by the occasional demand made upon the physician by the 
sexual hypochondriac, who regards these lesions with a degree of 
alarm which he can best appreciate who has been confronted with 
these cases. 

Prognosis. — As the disease tends naturally to a spontaneous, though 
occasionally long-deferred resolution, the prognosis is favorable. 
Treatment in many cases will accomplish much in hastening the re- 
sult. The most obstinate forms are those in which the face, back of 
the ears, inside of the auricle, neck, and shoulders are studded with 
relatively small, indolent comedo points, about which the orifice of 
the duct rises in a whitish rim. This, when felt with the finger, 
produces the impression of hyperplasia of the wall of the duct. Such 
eases, however, are nearly allied to the forms of acne described else- 
where. With exceeding rarity, the comedo is merely the first step of 
a more serious local affection. In early life a single prominent lesion 
is formed, and though the plug be frequently removed and finally be 
no longer reproduced, the orifice of the duct remains patulous in 
middle life. Slowly thereafter its walls undergo a metamorphosis 
and a warty epithelioma results. 

Cyst. 

Gr. h'ictlq, a bladder. 
Sebaceous cysts are millet-seed to egg sized and larger, milky-whitish, or 
yellowish-white, encysted tumors of the sebaceous glands, occasionally 
having the color externally of the normal integument, either imbedded 
within the skin or projecting above it. 

The term sebaceous cyst is applied by some authors to one merely 
of the two disorder- of the skin to which it properly belongs, viz., 
the wen. In these pages it includes both milium and steatoma. 

I A] Milium. 
Lat. milium, a millet-seed. 

Symptoms. — Milia, also called Grata, occur upon and about the 
eyelids, the cheeks, the temples ; the penis, scrotum, and corona 



CYST. 125 

glandis of men ; and the internal face of the labia minora of woman. 
They are millet-seed to pin-head sized, globoid masses, rarely at- 
taining the dimensions of a coffee-bean, showing within the epidermis 
as though kernels of rice were lying there immediately beneath a 
translucent layer of tissue. They occasionally project from the 
surface to such an extent as to resemble small-sized vesicles filled 
with milky contents. In color they are yellowish and whitish. 
They are often congenital ; and can be recognized about the lids and 
temples of the newly born infant ; they are also seen, however, in 
middle life, when they develop very slowly, and sometimes persist 
for years. They are often observed in the neighborhood of cica- 
trices, which latter in such cases have usually been effective in their 
production. They occasion no subjective sensation, and are usually 
so insignificant as to induce no deformity. They never degenerate 
by ulcerative processes, but when not artificially removed are, in the 
course of years, exfoliated in the natural processes of physiological 
desquamation. 

Etiology. — Milia are at times produced mechanically, the stroke of 
a knife-blade, accidentally or by the processes of surgery, separating 
one or more of the acini of a sebaceous gland from the main body. 
The contracting bands of a cicatrix, after the destruction of tissue 
from any cause, may operate in a similar way with a precisely 
similar result. Having this in view, it may be said generally that 
milium is always the result of a cause which prevents the transform- 
ation of the epithelium lining the gland into fat, and the subsequent 
excretion of this upon the free surface of the skin. These causes are 
thus, for the most part, obscure, but all are probably of purely local 
significance. 

Pathology. — When a milium is incised externally, a spherical body 
of nearly corresponding. size may be expressed, though it may require 
tearing from a minute pedicle below, which represents the attach- 
ment to the hair-follicle. The small mass thus extracted is then 
seen to be composed of several thin envelopes suggesting the capsules 
of the onion, and representing cornified epithelia not undergone fatty 
metamorphosis, in the centre of which is a fatty nucleus. This mass 
represents the contents of one or more acini of a superficially situated 
sebaceous gland, cut off from the main body of the follicle in the 
manner described above, and always covered when in situ, as Kaposi 
has shown, by a delicate layer of the superimposed corium containing 
papilla?. Usually the orifice of the excretory duct cannot be appreci- 
ated in milia, though occasionally these lesions are developed when 
the orifice is patulous. 

These singular bodies do not always represent conditions of 
mechanically pent-up sebum, as the epithelia from which their con- 
tents are produced seem at times indisposed to fatty transformation 
and particularly apt to develop into horny or other formations. Thus 
Foster, of Boston, describes one where the process of calcification had 
been apparently complete ; Wagner has observed colloid contents in 
certain opalescent lesions which appeared in the cheeks and temples 



126 DISEASES OF THE SKIN. 

of a woman ; Barensprung and Hebra report numbers of acutely pro- 
duced niilia following pemphigus and erysipelas; and Virchow and 
Rindfleisch describe milia of the hair-sac and similar lesions accom- 
panied by cysl of the hair-follicle adjacent. It would seem rational 
to conclude that, in cases, the cause of milia is to besought in obscure 
changes by which the epitnelia of the gland are primarily a fleeted. 

Robinson believes that milia originate from miscarried embryonic 
epithelia from a hair-follicle or from the mucous layer of the epi- 
dermis. 

Diagnosis. — Milia might be mistaken for minute vesicles contain- 
ing a milky fluid, but puncture of the lesion, with expulsion of its 
contents, would at once disclose the character of each. Comedones 
with blackish external points, surrounded by the patulous orifice of 
the excretory duet and prolonged more deeply into the substance of 
the skin, could scarcely be confounded with milia. 

The most minute of the lesions of xanthoma have a yellowish 
color and cannot be as readily scraped away from the subjacent tissue 
as can milia. 

Treatment. — Milia rarely require treatment, as they are usually 
relatively few in number, and produce neither subjective sensation 
nor deformity. If desired, they may be opened with a fine milium 
needle, and their contents turned out. To insure their non-recurrence, 
the little sac left after the operation may be entered with a needle 
dipped in a fifty per cent, solution of chromic acid. This operation 
may have to be repeated in the rare cases where the lesions exhibit a 
special tendency to recur. 

The simplest and most elegant method of removing these and many 
similar-sized lesions of the skin is by the galvanic battery. With 
from four to six cells in the current, the negative pole is connected 
with a fine needle which is introduced within and beneath the lesion, 
Avhile the moistened sponge of the positive pole is in contact with the 
skin of the patient. The operation is bloodless and effectual; insig- 
nificant or no scars resulting. 

The prognosis is always favorable. 

[B.] Steatoma. 
Gr. G-Edp, fat. 

This form of sebaceous cyst is also called Wen, and Atheroma. 

Symptoms. — The history of the development and career of wens 
does not greatly differ from that of milia, already described. They 
are usually slow of growth; unattended by subjective sensation; 
occur as single or multiple tumors on the head, trunk, or genitals; 
and, being larger than milia, may attain the size of a hen's egg. 
They are situated beneath, within, or upon the skin; are usually un- 
attached to the deeper contiguous tissues ; and develop into irregularly 
globular, occasionally large button-shaped, masses, covered by an 
integument usually unprovided with hairs. This envelope may be 
quite normal in hue; or unnaturally whitish from pressure; Or,, 



CYST. 127 

especially upon the bald scalp of certain fleshy men of middle years, 
reddened, shining, and greasy in appearance. At times they are to 
be distinguished only by passing the fingers through the long hairs, 
of the scalp beneath which they are 
hidden ; at others, they are so con- Fig. 30 - 

spicuous in consequence of physio- 
logical alopecia as to occasion consid- 
erable disfigurement. They vary 
greatly in consistency, but usually 
produce to the touch a certain feeling 

of elasticity, especially if the cyst be •! ---.■■ <i, 

tensely distended. They are rarely '■ ■*&**, • i[ 

attacked by inflammation, resulting ~5fiflj .-'f ' 

in suppuration and ulceration. :. ,- 

Tumors of this kind are rarely 
exceedingly numerous. MacLaren's ~ffj ' y " "<^ "-'■ '" ■• ',:. 

patient, 1 a lad nineteen years old, ex- : - . 

hibited tumors over the entire sur- ^f?7 ; 

face of the body, which proved on { '/ ' 

examination to be sebaceous cysts, 
but which presented all the appear- ~~"-9-'' '_,' ' 

ances of multiple fibromata. „ t _ , _ a , . , ., 

7 -\ir Cystsof the scalp, one of them being laid open 

Pathology. — Wens represent an to show its contents. (Ghoss.) 

advanced grade of distention of the 

sebaceous glands by their contents, and a response to the constant 
pressure in hypertrophy of the glandular envelope. Their contents 
are semi-solid, curdy, cheesy, and granular ; or fluid and milky ; or 
fluid and purulent. These are the inspissated or chemically altered 
products of the gland secretion, recognizable as such by the materials 
of which they are composed, masses of fat and debris of epithelia, 
with an occasional lanugo or undeveloped hair. 

Diagnosis. — Steatomata are to be distinguished from fatty tumors, 
which, however, are more commonly observed about the scapulae, 
loins, buttocks, and extremities ; while wens are very rare except 
about the scalp and neck. They lack also the peculiar " pillowy " 
feel of fatty tumors. Suppurating wens in these regions may readily 
be mistaken for circumscribed abscesses, if regard be not had for the 
history of the tumor usually long preceding. Syphilitic nodes of 
the same part are usually both tender and painful ; osteomata are 
also firmly attached. 

Treatment. — The removal of a wen is accomplished by excision, 
after previous puncture of the sac, and the removal of its contents. 
Several fatal cases, -however, are on record as the result of this 
operation ; due not so much to the nature of the excised tumor as to 
its situation, surgical wounds of the scalp being particularly liable 
to erysipelatous and other complications. As the incision required 
for the removal of the wen must necessarily extend for some distance- 

i Brit. Med. Jonrn., Oct. 1SSG. 



128 DISEASES OF THE SKIX. 

on either side of the tumor, a linear scar results which on the bald 
scalp is often very conspicuous as a relic of the lesion. In conse- 
quence of the possibility of clanger, many surgeons prefer destruction 
of a prominent section of the mass with acid or alkali, leaving the 
sac, after expulsion of its contents, to wither gradually, though it 
may then he often withdrawn by forceps. 

Complete obliteration is sometimes effected by puncture, expression 
of contents, and the subsequent induction of artificial inflammation in 
the walls of (he cyst by injection of tincture of iodine, pure sulphuric 
ether, and other irritating fluids, as iu the operation for the relief of 
hydrocele. With the antiseptic precautions observed in surgical 
practice to-day, the removal of these lesions from any part of the 
body may be regarded as unattended with great risk. 

Prognosis. — The removal of the wall of the cyst is not followed 
by a return of the lesion. In debilitated and cachectic patients there 
may be spontaneous ulceration and sloughing, with or without 
surgical interference. Mr. Thomas Bryant 1 reports a carcinomatous 
tumor following the removal of a steatoma from the buttock of a 
woman sixty-three vears of age. 



Asteatosis. 

Gr. a, primitive ; ariap, fat. 

Asteatosis is that condition of the skin in which there is absolute or relative 
deficiency of the sebaceous secretion. 

Symptoms. — Insufficient lubrication of the skin by its natural 
unguent may be either general or partial, and occur either as an idio- 
pathic or symptomatic disorder. It is produced artificially by any 
agents which continually withdraw the fatty substance from the skin 
surface, as in those trades necessitating the constant immersion of 
any parts of the body in strong alkaline solutions, or waters highly 
impregnated with the salts of lime and potash. As an idiopathic 
affection, it is of very rare occurrence, but it is not an infrequent 
accompaniment of other local or constitutional diseases, such as 
psoriasis, lepra, angioma pigmentosum et atrophicum, ichthyosis, and 
lichen ruber. In these cases the skin becomes dry, often thickened 
and indurated, and, as a consequence, friable, prone to desquamation, 
fissures, and chaps. When handled, the absence of sebaceous secretion 
is noticeable in the objective sensation produced. It is a well-marked 
feature of the marasmus of old age. Some authors have described, 
under this title, the dry thickening and induration of the palm of the 
hand, accompanied by curving of the fingers toward the plane of their 
flexor tendons, which is occasionally to be observed among laun- 
dresses. But considering the absence of sebaceous glands from the 
palm, where in the author's experience this affection is most pronounced, 
it should be properly excluded from the list of sebaceous disorders. 

1 Brit. Med. JourD., May 31, 1884. 



EXANTHEMATA. 129 

Treatment — No internal medicaments are known to have the power 
of stimulating especially the sebaceous secretion. None, indeed, could 
be capable of having such action when, as is often the case in the 
disorders described above as characterized by asteatosis, there has 
resulted an atrophy of the sebaceous glands. The most that can be 
accomplished is the external application of an artificial unguent ; and 
for this purpose cod-liver oil, almond oil, palm oil, vaseline, lard, or 
butter may be employed. Vaseline is in many cases to be preferred, 
as the other articles named are liable to become rancid after oxidation, 
and thus act as irritants to the skin. With such partial or general 
lubrications, however, a warm bath with soap and water should be 
ordered every second or third day, immediately after which the 
inunction may be repeated. 

Prognosis. — In all those cases where the asteatosis is induced by 
agents operating externally upon the surface, a reasonable hope of 
recovery may be entertained after the withdrawal of the cause. Per- 
sistence of the latter is liable to be succeeded by the occurrence of 
eczema or dermatitis medicamentosa. A complete cure can scarcely 
be expected when this condition is really a symptom of one of the 
disorders already named. 



CLASS II. 

INFLAMMATIONS. 

Exanthemata. 

Gr. e^dv67/fia, blossoming, flowering. 

The Exanthemata are specific fevers, frequently occurring in epidemic form, 
communicable by contagion, preceded by a period of incubation, and char- 
acterized by systemic disturbance, with an efflorescence upon the skin, of 
different type in each, as also by involvement of other organs of the body, a 
single attack often conferring immunity upon an affected individual during 
his or her lifetime, against subsequent attacks of the same disease. 

For a detailed consideration of the phenomena of the exanthema- 
tous fevers, the reader is referred to the standard treatises on the 
subject, in the field of general medicine. Brief space is allotted 
here, merely to a description of the cutaneous lesions by which they 
are severally characterized. These are unlike in each disease; and yet 
all exhibit certain common characteristics. In all, the eruptions are 
symmetrical ; and in typical cases, general. In each, the efflorescence 
is succeeded by a desquamative or exfoliating condition of the skin. 
In each there is, within relatively fixed limits, a distinct stadium of 
the pathological process, within which it is completed, and beyond 



130 DISEASES OF THE SKIN. 

which, however persistent may be its remote sequelae, there is no 
chronic manifestation of the disorder. Each also is produced solely 
by its own specific contagium, derived exclusively from an animal 
body affected with the same disease, being never, so far as known, 
generated from any other source, nor merging by imperceptible 
degrees the one into another. Two of these may rarely concur, but 
under such circumstances the one is always pronounced in its 
teat un-, which either closely precede or follow those of another. 
No specific medication is known to be capable of arresting any one 
of them, each pursuing its course uninterruptedly to a favorable or 
fatal termination, according to the intensity of the poison present in 
each ease, and the more or less favorable or unfavorable conditions 
of the sufferer. Finally, it seems probable that, at no distant date, 
specific bacteria or micrococci will be demonstrated to be etiological 
factors in the production of each. 

Morbilli. 

(Measles, Rubeola.) 

Measles is a specific, contagious, febrile disorder accompanied by a cutaneous 
exantbeni and an acute catarrh of the mucous surface of the respiratory 
tract. 

This disease is preceded by a period of incubation lasting from 
eight to twenty-one (usually from ten to twelve) days, a period in 
which there may be no evidence of ill health, or merely a moderate 
degree of lassitude and inappetence. To this succeeds a prodromic 
fever, the temperature rising to 103°-104°F., occasionally alter- 
nating with chills, or a sensation of chilliness, dryness of the skin,, 
pains in the head, thirst, occasionally sweating, rarely convulsions in 
children, and, almost invariably, a serous catarrh of the mucous 
surfaces. By the second or third day the temperature begins to 
decline, while the catarrhal symptoms increase. These are mani- 
fested in sneezing, a copious secretion from the eyes and nose, and 
engorgement of the exposed mucous surfaces, especially of the con- 
junctiva, nares, and throat. Occasionally, the tongue and fauces 
exhibit a few isolated, minute, reddish puncta. In consequence of 
the implication of the larynx, trachea, and ultimately the larger 
bronchi, there is a hoarse, frequently an incessant and teasing cough, 
of a convulsive character, accompanied by expectoration of mucus 
in moderate quantity. This prodromic period lasts from three to 
five days, but is, in exceptional cases, prolonged to twice that length 
of time. Upon its conclusion, the exanthem appears, usually on 
the fourth day, with aggravation of the fever, the temperature rising 
to 104°-106° F., and remaining at that point till the eruption has 
reached its apogee, when it commonly declines pari passu with the 
severity of the skin symptoms. 

The eruption of measles usually appears first upon the face (the 
forehead and temple), and thence extends in about thirty hours over 



MOEBILLI. 131 

the neck, upper portion of the trunk, and superior extremities. 
Between the fourth and sixth days of the disease, it has usually 
attained its deepest shades of color, and its maximum of development 
over the entire surface of the body, including the palms and soles. 
This maximum attained, the eruption gradually fades; the tumid 
condition of the skin, most noticeable on the face, also subsides ; the 
catarrhal symptoms and cough become less annoying; and the patient 
enters upon the period of desquamation. 

The eruption is characterized by the occurrence of reddish, yellowish- 
red, mulberry-red, deep raspberry-red, or, in extreme cases, viola- 
ceous-tinted, small finger-nail sized niaculse, either not elevated or 
very slightly raised above the general level of the integument; 
or by the occurrence of large pin-head sized, discrete papules, much 
more rarely pin-point sized vesicles, corresponding in color to the 
shades described above, and highly suggestive of the first efflorescence 
in variola. These lesions become pale under pressure, exhibiting 
then a yellowish tint, and are often set together very closely, particu- 
larly over the upper segment of the body, in patches suggesting a 
crescentic outline. The term " suggesting " is here used purposely ; 
as it is difficult, by selecting a single patch, to determine by the eye 
alone the existence of such a configuration ; while yet an examination 
of the eruption as a whole may often very clearly convey this 
impression to the sight. In other words, the crescentic outline is far 
less distinct than, for example, in certain of the papulo-crustaceous 
syphiloclermata. Usually, patches of sound skin can be recognized, 
even when the eruption appears to be confluent, complete confluence 
never occurring so as to form a sheet or mask over an entire area 
of the skin. Individual lesious may so merge as to be well-nigh 
indistinguishable separately ; yet, on the whole, the eruption deserves 
fully the plural character of its English name. It is made up in all 
cases of innumerable elements, whose identity is never wholly lost. 
The subjective sensation awakened is occasionally a severe itching or 
burning ; frequently this is a matter of insignificance in comparison 
with other disagreeable symptoms — e. g., the cough, coryza, and fever. 

Desquamation is accomplished usually with cessation of fever and 
the production of yellowish-brown pigmentations of the surface 
where the elements of the eruption have existed, involution being 
first manifested in the site of the lesions which were earliest to 
develop. Gradually and simultaneously, the catarrhal symptoms of 
the respiratory passages diminish in severity. This final stage of 
the disease is usually terminated in a fortnight from the date of 
invasion. 

The complications and anomalies of measles depend: upon the 
intensity of the poison, displayed in the most formidable symptoms 
where human beings are crowded together, as in camps and prisons; 
upon the degree of physical vigor; and also upon the various 
hygienic surroundings of the victims of the disease. Thus, the 
period of efflorescence may be unusually prolonged ; the eruption may 
disappear suddenly, and as rapidly reappear ; the cutaneous symp- 
toms may alone be wanting ; the latter may be commingled with 



132 DISEASES OF THE SKIN. 

petechia' due to cutaneous extravasation of blood, which may be 
also accompanied by severe epistaxis; and the catarrhal condition of 
the mucous surfaces affected may terminate in croupal or diphthe- 
ritic disease, may be followed by capillary bronchitis, catarrhal 
pneumonia, and even by pulmonary tuberculosis. Typhoid condi- 
tions may also supervene, and chronic inflammatory affections of the 
eyes and of the Schneiderian membrane result. 

The pathology of the cutaneous lesions in measles is that merely 
of acute hyperemia occasionally passing into exudation, limited for 
the most part to the vascular ■ papillae of the corium and the peri- 
follicular plexuses of bloodvessels. Post-mortem, the eruption fades, 
as the result of the gravity of the blood, from the anterior aspect of 
the body as it reclines upon the dorsum. 

While it is possible that the cause of this disease will be one day 
demonstrated to depend upon some of the inferior organisms, no 
observer can yet claim to have conclusively established the fact. 
Bacteria, of small size and great mobility, have been found in the 
blood by Coze and Feltz ; micrococci in the trachea by Klebs ; 
spherical bodies in the breath of children, and, post-mortem, in the 
lungs and liver by Braidwood and Vacher ; and similar organisms 
in the vesicles and pustules of malignant measles by Keating and 
Forinad. 1 

The disease is one of infancy chiefly, probably because at that age 
there is always the largest number of individuals unprotected by 
previous attacks. In every case, the malady results from contagion, 
mediate or immediate, from an infected human subject. It spares no 
age or sex, though much rarer in advanced years than at other 
periods of life, probably because of the large number who, at such 
periods, enjoy immunity. 

The diagnosis of importance is between scarlatina and variola. 
Typical cases with a well-developed eruption can be scarcely mis- 
taken for either, if the symptoms displayed are assigned their full 
weight. It would be useless, however, to deny the fact that atypical 
forms occur, which have again and again confused the most expert 
diagnosticians ; and in all cases of doubt the prudent practitioner 
will refuse to decide as to the nature of the disease till the symptoms 
have, in the lapse of time, been fully declared. The resemblance 
between illy-developed measles and certain of the eruptions seen in 
varioloid, is in the highest degree striking ; and the greatest skill, at 
a given moment of time, will in cases utterly fail to make a decision 
between the two. A distinctly crescentic character of the eruption, 
the presence of catarrhal symptoms, the continuance of the fever after 
the efflorescence is completed, the color of the eruption, and the dis- 
covery of the nature of the disease from which the contagion was 
derived, will all point in the direction of the truth. From scarla- 
tina, measles is much more readily differentiated by the macular or 
papular elements of its eruption ; by their color ; by their appearance 
to a marked degree upon the face ; and by the absence of the charac- 

1 See Sternberg's Maguan's "Bacteria." New York, 1884. 



ROTHELN. 133 

teristic sore throat and usually intense febrile access of the first named 
disease. From the various forms of erythema accompanied by fever, 
measles can always be distinguished by the irregularity of the tem- 
perature record, as well as by the character of the eruption. The 
distinction between rubeola and rotheln is given later. 

The treatment of measles should be strictly limited to a careful 
hygienic attention to the invalid, including a restricted " fever diet/' 
and the use of such medicaments only as are especially indicated by 
been followed by fatal results when employed as an antithermic, has 
the complications or accidents of the disease. Antipyrine, which has 
been already superseded in cautious hands by antifebrin, which may 
share a similar fate when better understood. 

In the way of local treatment, the skin should be anointed with a 
bland, oily, or fatty substance, to relieve the pruritic sensations, espe- 
cially after the sponging of the surface once daily with a weak alka- 
line solution, which may be used cool without fear of producing 
" repercussion " of the exanthem. The chamber of the invalid should 
be somewhat darkened for the sake of the eyes, but pure air should 
be constantly admitted. 

The prognosis is, in general, favorable. All the complications 
named above increase, however, the gravity of the disease, which is 
also enhanced among men crowded together in camps, infants in 
public charities, pregnant women, the cachectic and greatly enfeebled 
from other diseases, very young infants, old men and women, and 
residents of islands that have been long unvisited by epidemics of 
the malady. 

The disease has been demonstrated to produce itself by contagion 
two to four days before the appearance of the rash, while the power 
of such transmission is usually lost between the twentieth and thirtieth 
days after the exanthem is fully developed. 

Rotheln. 

(Rubella, German Measles, Hybrid Measles, French Measles.) 

Ebtheln is a specific, feebly contagious, febrile disorder, often epidemic, 
- accompanied by a characteristic exanthem. 

The disease has an incubative period lasting from fourteen to 
twenty-one days, followed either by the eruption or by brief pro- 
dromes lasting from a few hours to a single day. These are feelings 
of malaise, cephalalgia, articular pains, anorexia, and nausea. The 
occipital, cervical, and other glands may at this time become large 
and tender. After a pyrexic period, rarely lasting longer than a 
few hours and in many cases entirely absent, the eruption appears, 
occurring for the most part in the regions affected by measles; in 
the form of multiple, pin-point to small pin- head sized macules, 
but smaller than the lesions displayed in that disease, and decidedly 
lighter in color. The shade is rosy to a crimson-red, rarely lurid, 
never of dark mulberry or violaceous hue. This color will, at times, 
be perceptible beyond the line of the lesions, in a delicate halo, a 



134 DISEASES OF THE SKIN. 

circumstance which strongly distinguishes the exanthem from mor- 
billi. The lesions, moreover, are .seldom arranged in crescentic 
outline, being more ofteu grouped iu roundish or oval patches. 
( )l'i»'ii, indeed, the elements of the eruption are discrete and dissemi- 
nated. The fauces are occasionally reddened in puncta. The erup- 
tion commonly fades in from one to two days, and there may or 
may not be slight resulting cutaneous desquamation. 

The rash is to be distinguished from that of measles by the recog- 
nition of the features described above, particularly by the color, 
contour, and date of occurrence of the exanthem; the transitory 
character of the fever when the latter is present ; and the rapidity 
with which involution of the disease progresses. By the temperature 
record alone of the patient, it may be differentiated from scarlatina, 
though the rash is dissimilar iu the two diseases. It is also not to 
be confounded with the erythematous affections of the skin. One of 
the most striking characteristics of the disease can be best recognized 
in a ward filled with children, all of whom are simultaneously affected 
with the disorder. That characteristic is the remarkable mildness of 
the phenomena displayed in every case. The author has had under 
observation at one time twenty little patients all exhibiting the exan- 
them, not one of whom presented the peculiar facies of the sufferer 
from measles. 

After an exhaustive study of this disease, Atkinson 1 concludes that 
while its characters are so defined as to justify a reasonable certainty 
in its diagnosis, it has no symptom that is not often assumed by 
measles. 

, The disorder should be treated by rest in bed, a supply of fresh 
air, and the usual diet of fever patients. Medication by drugs is 
almost never indicated. 

Scarlatina. 
(Scarlet Fever, Scarlet Rash.) 
Scarlatina is a specific, contagious, febrile disorder, characterized by a 
cutaneous exantbem, and by involvement of the throat and other bodily 
cgans. 

The period of incubation of scarlet fever varies between twenty- 
four hours and a month or more, the average duration being about 
eight days. The reason of this wide variation is to be sought, not in 
any changeability in the mode of evolution of the disease, but in the 
fact that its poison is less volatile and less rapidly dissipated than is 
that of measles, the result being that it may remain potential for 
longer periods in connection with articles through- the medium of 
which it is transferred from one individual to another. This incu- 
bative period, like that described in connection with measles, may be 
quite unproductive of physical symptoms, or be associated with an 
ill-defined malaise. 

The prodrome of the disease in typical cases, is marked by the 
occurrence of a rapid and bounding pulse, an exceedingly dry skin, 

1 Amer. Journ. of the Med. Sci., 1887. 



SCARLATINA. 135 

and a characteristic sore throat. When examination of the month is 
made, the tongue is seen to be thickly coated, and its filiform papilla? 
reddened and prominent, producing the so-called " strawberry ap- 
pearance." The velum, pillars of the fauces, tonsils, and all exposed 
mucous surfaces are engorged, tumid, reddened, and often covered 
with deep reddish puncta, which unquestionably represent hyperemia 
of the perifollicular tissues. Thirst is great, and deglutition often in 
the highest degree painful. In severe Cases, the mucous surfaces 
named may speedily exhibit finger-nail to pigeon's-egg sized, ashy 
ulcerations with a lurid halo at the periphery. In children, there 
may be syncope, delirium, convulsions, vomiting, or, when the poison 
has been intense, fatal results from shock of the nervous centres. 
This prodromal period usually lasts from twelve to twenty-four 
hours, though it may be prolonged for two days more. In this 
respect scarlatina is markedly distinguished from measles. This stage 
is terminated by the appearance of the exanthem, but the fever per- 
sists without abatement after the explosion ; and the other symptoms 
of the disease are then in no wise ameliorated. 

The eruption in scarlatina usually spares the face, however much 
the latter may display two damask-colored cheeks under the febrile 
flush, become tumid Math the acceleration to it of the blood pumped 
through the throbbing carotids, or even exhibit a few scanty lesions 
upon the forehead and temples. About the mouth, the integument 
is always pallid. This is far different from the picture presented in 
measles. The eruption is first seen in the form of light or deep red, 
pin-head sized puncta, so closely agglomerated as to produce upon the 
eye the impression of a diffuse reddish blush. It is first seen about 
the neck and clavicular regions, but rapidly spreads to the trunk and 
extremities, including the dorsal surfaces of the hands and feet, 
attaining complete development in the course of the second day of the 
eruption. It is then of a distinctly scarlet color, whence the disease 
has its name in the Latin, English, and German tongues, a coloration 
frequently compared to the appearance of a boiled lobster. Upon the 
limbs it is often developed in punctate form, while the occurrence of 
a diffuse scarlet blush is most distinctly perceived by the eye in the 
examination of the trunk. Here it is seen to fade under pressure ; 
and the finger-nail drawn rapidly over the surface of the skin is fol- 
lowed by the formation of a whitish line, which persists for an 
instant, a time sufficient to enable one to describe a letter upon the 
skin. This period of efflorescence lasts for from one to two days to 
an entire week, during which, as stated above, the febrile and other 
symptoms continue unabated. 

The rash usually persists at its maximum of development for from 
one to three days, the concomitant symptoms continuing without 
noticeable abatement. Among the latter may be named the occur- 
rence of albumen in a urinary secretion of diminished specific gravity, 
with occasionally the presence of epithelium recognizable uuder the 
microscope as derived from the lining membrane of the uriniferous 
tubules of the kidney. 



136 DISEASES OF THE SKIX. 

Having attained its apogee, the eruption in favorable cases begins 
to lade, the part first affected exhibiting earliest a lighter shade, while, 
the other pathological phenomena diminish in severity, the sore 

throat, especially in ulcerated conditions, alone persisting. In from 
four to ten days longer the eruption disappears, leaving a brownish- 
yellow pigmentation of the surface; and simultaneously the other 
symptoms of disease vanish. 

The desquamation which then ensue-, as convalescence progresses, 
is general and often proportioned in extent to the severity of the. 
preceding eruption, though it may be generalized after a well-nigh 
imperceptible exanthem. It is more pronounced and characteristic 
in scarlatina than in any of the other eruptive fevers. It may be 
superficial and furfuraceous in character; or the epidermis may fall 
in lamellated plates, the sheath of an entire finger, for example, with 
the nail ; or that of the entire palm. In this way sheets, ribbons, 
and shreds of the horny layer of the skin may fall from its surface, 
and expose beneath a new and often tender epidermis. The hairs 
may be simultaneously shed. When this desquamation is finished, 
the stadium of the disease may be regarded as concluded, the entire 
period lasting in uncomplicated cases from a fortnight to a month or 
six weeks. 

The complications, anomalies, and remote sequelse of scarlatina are 
so numerous as to furnish a vast array of facts for the study of the 
pathologist. The reader need be merely reminded in these pages 
that the usual incubative and prodromic stages of the disease may be. 
brief as to time, or so brusquely followed by eruptive phenomena as 
to be indistinguishable. The latter may also first occur upon the 
extremities or trunk, and later on the neck and over the clavicles ; or 
at once cover the totality of the surface by a rapid explosion : or be 
extremely short-lived ; or be altogether absent ; or be unusually pro- 
longed and visible for even a fortnight upon the surface of the body, 
appearing and well-nigh disappearing without appreciable cause. 
To a proportionate extent, the stage of desquamation may be preco- 
ciously or tardily reached, and the exfoliating process be tediously 
prolonged and of intense type, jeoparding in this manner the future 
of the convalescent prostrated by the fever which has passed, or the 
sympathetic fever which may thus be awakened. 

The anomalies of the scarlatinal rash are numerous, but depend, in 
general, less upon a variation in the intensity of the poison than upon 
the physical condition of the patient. Thus, the affected surface may 
be slightly elevated above the general level ; may exhibit irregularly 
disposed mottlings and maculatious ; may be characterized by the 
occurrence of miliary papules, minute vesicles, or purpuric lesions 
well defined against the general scarlet color of the skin by their vio- 
laceous shade, and due to cutaneous extravasation of blood. The 
rare bullous, pustular, and urticarial lesions which may appear upon 
the skin, are accidental, and bear no relation to the specific history of 
the disease. 

Malignant angiuose scarlatina is characterized by the gravity of 



SCARLATINA. 137 

the throat symptoms. In such cases, a parenchymatous inflammation 
of the tonsils, velum, and fauces supervenes at an early period, with 
enormous tumefaction, involvement of the submucous tissue and 
neighboring glands, and ulcerative, suppurative, and even gangrenous 
results, which may prove speedily fatal. Gastro-intestinal disorders 
may also prove dangerous. An otitis externa, media, or interna, 
may perforate the tympanum, destroy the ossicles, induce caries of 
the mastoid process of the temporal bone, and prove fatal by the 
eventual production of meningitis or phlebitis. 

Another severe type of the disease is that in which symptoms of 
typhus are pronounced (Scaklatiniform Typhus). Here the patient 
may perish within a few hours after being attacked and before the 
eruption appears, exhibiting comatose or convulsive symptoms indi- 
cating the profound influence upon the nervous centres of the intensely 
intoxicated blood ; or the eruption may have time to appear, often 
livid, hemorrhagic, or petechial in type, and be followed by albu- 
minuria, meningitis, diarrhoea, coma, and death. Catarrhal and 
parenchymatous nephritis are justly dreaded during the desquamative 
period of the malady, when they may prove fatal after a relatively 
benignant manifestation of the disease in its prodromal and eruptive 
stages. To this sufficiently grave list of disorders which may com- 
plicate scarlet fever, must be added pneumonia, pericarditis, pleuritis, 
peritonitis, chronic purulent nasal catarrh, which may result in caries 
of the nasal bones, destruction of the cornea as a result of severe 
keratitis, persistent adenopathy of the subcutaneous glands, and 
malnutrition in many forms, which may so impair the vigor of the 
constitution as to leave the sufferer a physical wreck for the remainder 
of life. 

The cutaneous lesions of scarlatina, like those of rubeola, depend 
upon hyperemia and a moderate degree of exudation. The latter, 
when it occurs, is limited for the most part to the rete and papillary 
layer of the corium. The signs of the disorder are not apparent in 
the dead body, unless there has been exudation of blood and the 
consequent formation of petechise. 

The disease is produced exclusively by contagion derived from the 
animal body affected with scarlatina, either mediately or immediately. 
It attacks individuals of both sexes and all ages, children and infants 
more frequently, the aged more rarely, probably in consequence of 
their respective conditions as regards immunity conferred by a previous 
attack, since, in general, the disease occurs but once in a lifetime. 
Individual idiosyncrasy must account for the cases in which unpro- 
tected infants exposed to the disease fail to receive it, a fact noted 
occasionally in all the exanthemata. The contagious element is 
volatile in its nature, and seems to be most active during the eruptive 
stage of the disease. 

Rod-like bodies and mobile points have been found by Eeiss, Coze, 
and Feltz in the blood of patients affected with scarlet fever; and 
injection of rabbits with such blood has proved fatal. Drs. Jameson 



138 



DISEASES OF THE SKIN. 



and Edington 1 have lately recognized and cultivated the "bacillus 
scarlatina," measuring0.4 mm. in thickness and 1.2-1.4 mm. in length, 

forming long, jointed, and curved, motile leptothrix filaments. Ex- 
ceedingly interesting clinical facts as to the transmission of scarlatina 
through the medium of the milk of diseased cows have been lately 
determined by some of the Ideal health hoards in Great Britain. The 
disease at times follows injuries and surgical operations, due, as 
Atkinson- supposes, to diminished powers of resistance to the disease. 

Fig 31. 





Micro-photograph of the edge of a small colony of the hacillus scarlatina?. 
a. Central zone. b. Outer edge of growth. 

The diagnosis is between measles, rotheln, erysipelas, and the 
erythemata ; and is, iu general, readily established. The sore throat, 
intense fever, pnnctiform scarlet rash reaching to the border of the 
inferior maxilla, and the distinct, whitish-yellow line traceable by the 
finger-nail passed rapidly over the surface, are all characteristic. Iu 
measles, the macular character of the rash, and its crescentic arrange- 
ment, in connection with the catarrhal symptoms, will usually be 
recognized. From erysipelas, scarlatina can always be distinguished 
by the absence of the peculiar, shining, smooth, or glazed and tumid 
condition of the affected area. From all other rashes, scarlet fever 
can be distinguished by the pyrexic symptoms and resulting desquam- 
ation. 

Great care should be taken not to confound the medicinal rashes 
having a scarlatiniform appearance, with the specific disease under 



Brit. Med. .Tourii., June 11, 1887, and August 6, 1887. 
Jouru. of C'utau. and Ven Dis., vol. iv., Octoher, 188( 



VARIOLA. 139 

consideration. Thus belladonna, in closes of one minim of the tincture 
every hour to the extent of four doses, has produced an abundant 
scarlatiniform eruption in children, a diagnostic point of importance- 
in view of the fact that the drug named is employed popularly as a 
prophylactic against the disease. For the medicinal eruptions of this 
sort due to quinine and other drugs, the reader is referred to the 
pages devoted to dermatitis medicamentosa. 

The modern treatment of uncomplicated scarlatina is purely ex- 
pectant, after provision is made for an abundant supply of fresh air, 
disinfection, a proper regulation of food and drink, and the local use 
of baths, tepid or cool, for the purjDOse of reducing the bodily temper- 
ature. After each of these, the skin should be completely anointed 
with a fatty substance, such as cold cream, scented almond or olive 
oil; or, what is most commonly used in this country, vaseline. These 
inunctions are not only grateful to the patient, but, as the author has 
again and again demonstrated by the thermometer, reduce the tempera- 
ture to a slight degree. All other treatment than that suggested above, 
should be limited to the special conditions presented in each case, and 
pertains to the field of general medicine. It includes the manage- 
ment of disorders of the eye, ear, throat, kidneys, and other viscera, 
whose involvement constitutes a complication of the disease. 

The prognosis of the malady should always be established with 
reserve. It is largely based upon the relative intensity of the symp- 
toms, the vigor and age of the subject, and the presence or absence of 
serious complications. Albuminuria is rarely absent, and not per se 
alarming ; but anasarca and other evidences of profound interference 
with the renal function, are to be assigned due weight. In general, it 
may be said that a high range of temperature ; early and ulcerative 
throat lesions ; tardy development, rapid and untimely disappearance 
or undue prolongation of the exanthem ; and its admixture with 
petechia? to such an extent as to indicate extensive hemorrhagic ex- 
travasation, are all formidable symptoms. Finally, it must not be 
forgotten that the mildest and simplest forms of the disease, after the 
fastigium is passed and convalescence actually established, may termi- 
nate fatally by the supervention of ureemia, cerebral paralysis, or 
even meningitis, consequent upon secondary changes in the middle 
or internal ear. 

Variola. 

(Smallpox.) 

Lat. varus, a blotch. 

Variola is a specific, contagions, and febrile disorder characterized, when 
unmodified, by the appearance in succession upon the cutaneous surface 
and occasionally also upon the mucous surfaces, of papules, vesicles, pus- 
tules, crusts, and cicatrices. 

The variations of this malady as to the severity, character, and 
duration of its symptoms, are so great as to preclude its complete 
description within the limits here assigned to the subject. The fol- 



140 DISEASES OF THE SKIN. 

lowing paragraphs arc devoted to a brief sketch merely of its more 
commonly recognized characters. 

The period of incubation of the unmitigated disease varies between 
ten and twenty days, occupying usually a fortnight. It is character- 
ized by the peculiarities of that period recognized iu all the exan- 
themata, few and insignificant or no evidences of physical discomfort. 
The prodromic stage is ushered in generally by a vespertine chilly 
succeeded by fever, with a temperature rising to 104°-106° F., which 
is commonly associated with severe and characteristic pain in the 
loins, headache, nausea or vomiting, and occasionally, in young sub- 
jects, delirium and convulsions. The fever continues, with alterna- 
tions of exacerbation and partial relief, or sensations of chilliness, on 
the second and third days. At the same time there may be faucial 
hyperemia and moderate dysphagia. Occasionally, before the cuta- 
neous exanthem appears, minute reddish papules may be recognized 
upon the buccal membrane. 

On the second and third days there appears, in some cases, espe- 
cially in menstruating women and in young subjects, a cutaneous 
efflorescence, whose significance has been often misinterpreted and 
which has led to many errors in diagnosis. It is to Hebra that we 
are indebted for its distinct recognition as a cutaneous prodrome in 
variola. It has been termed Variolous Erythema, and Vario- 
lous Roseola. Its recognition is a matter of special importance to 
the diagnostician, as many have been deceived respecting its nature 
and significance. It is characterized by the occurrence of irregularly 
disposed and distinctly outlined maculations, puncta, stria?, streaks,. 
or a diffuse blush of bright or lurid reddish hue ; the invaded integu- 
ment being at times slightly tumid, and thus elevated above the 
general level. It may be also the seat of moderate pruritus. The 
blush may fade under pressure, but rarely does so perfectly. One 
cannot by the finger produce upon it a visible whitish spot. It occurs 
most often about the groins, hypogastric region, pubes, and inner 
faces of the thighs ; and, examining these parts, the physician will 
usually discover the evidence, in adult women, of recent or present 
menstruation, or of the puerperal state. It occurs also about the 
axillae, the extensor faces of the larger and smaller joints, and the 
lumbar and clavicular regions. Often a broad area of the integument 
in these parts may exhibit a sheet or mask of dull crimson erythema, 
upon which pin-head to bean-sized, dull-reddish papules may form, 
not losing their color under pressure, more rarely petechia?, vesicles, 
and wheals. All these are precursory phenomena, and are not trans- 
formed into characteristic variolous lesions. They fade almost com- 
pletely before the latter appear. Rarely, a few scattered papules may 
be distinguished upon the face and arms before the variolous erythema 
fades. Often the former in full development are even less profusely 
displayed in the site of the precedent efflorescence. The latter need 
not be necessarily regarded as a symptom of portentous gravity. The 
author has seen the entire surface of the belly covered with a uniform 
erythematous blush of dull crimson hue, confluent variola follow, and 



VARIOLA. 141 

the patient ultimately recover. The physician, then, in face of a 
deep red erythema of the regions named, especially of the groins, 
lower part of the belly, and thighs of a menstruating woman affected 
with high fever, nausea, vomiting, and lumbar pain, should invariably 
suspect the presence of variola. 

The period of eruption is characterized, at its earliest, by puncti- 
form, subcutaneous discolorations w T hich photography alone can reveal. 
Commonly, after three days of prodromic symptoms, the patient will 
be seen on the morning of the fourth with the face and scalp covered 
by pin-head sized and larger, firm, conical papules, whose impression 
to the finger is compared by most English writers to the feeling of 
shot. Later, these develop upon the trunk and limbs ; and in well- 
marked cases every portion of the surface of the body is invaded, 
including the palms and soles. The lesions may be surrounded by a 
narrow rosy areola upon the trunk. They may be unproductive of 
subjective sensations, or be slightly tender. 

As a rule, there is complete defervescence when the exanthem 
appears, the patient experiencing such relief that if an adult has 
chanced not to view the face in a mirror nor to be informed of his 
appearance by those in attendance upon him, he will often regard 
himself as completely relieved of his three days' illness. In other 
cases, the febrile symptoms persist, with a lowered temperature. 

During the first two days of the eruptive period, the papules in- 
crease in number, and become correspondingly agglomerated ; while 
those of earliest appearance become transformed into vesicles con- 
taining a translucent serum, the roof- wall of many of them exhibiting 
an umbilication. This umbilication of the vesicle is characteristic, 
and slightly different from that observed in bullous and pustular 
lesions. The central depression is disproportionately large, and 
about it the yet undistended epidermis is often irregularly puckered 
or fluted. Even in this period, the lapse of a few hours will produce 
a lactescent appearance in their formerly translucent contents. 

From the eighth to the twelfth day, the transformation of these 
lesions into pustules is effected, the process beginning, as in all the 
metamorphoses of the disease, in the vesicles of greatest age ; those, 
namely, on the face and upper portions of the body. The lesions 
simultaneously enlarge till they are of the average size of a pea, 
and, being fully distended, rupture the centrally placed filament 
which held down the roof- wall, in consequence of which the umbili- 
cation of the pustules is lost. With this process of suppuration, is 
awakened the so-called secondary fever, a pathological process evi- 
dently not essential to the disease, as it does not occur in mitigated 
cases. It is born of the extensive process of suppuration occurring 
in the skin and other organs, and may be symptomatic, sympathetic, 
or septicemic in character. It thus varies in different cases with 
the character and severity of the process by which it is excited, 
being transitory in mild cases, and in others terminating only with 
death. At this time the patient is usually in a most distressing con- 
dition. The skin of the face and other attacked regions 'is swollen, 



142 DISEASES OF THE SKIN. 

thickly covered with pustules, and the features indistinguishable in 
the tumid and closed lids, the oedematous lips, disfigured nostrils, and 
pus-obstructed mucous outlets. Deglutition becomes painful and 
often impossible; the saliva flows from the lips; and the mucus of 
the nares dries with the pus upon the exterior of the visage. The 
pustules recognized upon the iutegumenl arc represented also in the 
gastro-intestinal tract. In an autopsy of a patient dead at this stage 
of the disease, made by myself in company with Dr. MeGill, of the 
United States Army, during the kite civil war in this country, we 
discovered the entire canal from the mouth to the anus, as also the 
genito-urinary and respiratory passages, completely covered with 
closely agglomerated and well distended pustules. The career of 
those within the mouth can be usually studied by observation with 
the eye. In this situation they rapidly lose their epithelial roof-wall 
by reason of the heat, moisture, and friction to which they are sub- 
jected, and then exhibit a reddened and excoriated surface, over 
which there is reformation of the epidermal layer. Gangrenous 
complications are rare. 

Between the thirteenth and fourteenth days desiccation begins, 
and is usually completed within from ten days to a fortnight after- 
ward ; the pustules rupture, and the exuded pus concretes into yel- 
lowish and brownish, rarely blackish crusts, or the latter are formed 
by the desiccation of the entire envelope and contents. The pulse 
usually at the same time diminishes in frequency; a secondary defer- 
vescence occurs ; the tumefaction of the integument decreases; and 
at times the peculiarly characteristic, and often intolerably fetid odor 
of the patient is less perceptibly exhaled. In from four to six 
weeks the course of the disease is completed. The immediate traces 
of the eruption are purplish and violaceous pigmentations, which 
slowly disappear. When cicatrices result, they are slightly depressed, 
dead-white, lustrous, usually symmetrical in disposition, and most 
distinct upon the surfaces exposed to the light and air, as the face. 
Though persistent, they are rendered somewhat less deforming in 
the progress of years. When closely set together, they produce a 
characteristic ridged aud corded appearance, due to the elevation of 
narrow bands of unaffected integument between the depressed sur- 
faces of scars. 

The several departures from the pronounced type of the disease 
described above, present variations differing widely from the most 
benignant forms. Brief reference only can be made to these. 

VARIOLOID, whether occurring after vaccination or not, is a modi- 
fied form of the disease. With it should be classed all those forms 
of the disorder occurring in the human subject, and described by 
authors under the title of ''Swine-pox," "Horn-pox," etc. In these 
cases, there may be severe prodromic fever and a scantily developed 
exanthem ; mild fever, abundant exanthem, and rapid involution of 
lesions ; abortion of the latter in any of their several stages from 
papule to 'crust; absence of secondary fever; transmission of the 



VARIOLA. 14S 

disease in a mild or mitigated form, from one individual to another, 
so that an entire community, vaccinated and unvaccinated alike, may 
suffer from an epidemic disorder of this moderate grade without the 
occurrence among them of a single case of typical variola. It is 
scarcely necessary to add that the patient with varioloid, especially 
during an epidemic, may transmit to the unprotected a malignant 
form of the disease. 

Much more formidable, viewed from every standpoint, is Hemor- 
rhagic Variola, fortunately rare and too often confounded in the 
past with " black measles." When cutaneous haemorrhages occur 
during the course of smallpox, they do not necessarily indicate that 
the case is one of the so-called varioliform purpura, since these may 
be accidents of the pathological process. In this malignant form of 
the disease, against whose ravages vaccination seems to present no 
barrier, the prodromic stage is followed by a deep purplish redness 
of the surface which is characterized by pin-head to split-pea sized, 
firm, closely set, papular lesions, suggesting the occurrence of measles 
in a peculiarly severe form. The febrile, nervous, and other symp- 
toms of the disease are proportionately intense. Ecchymoses appear 
upon the conjunctival membrane. Gradually the color of the exan- 
them, which at first disappeared under pressure, refuses thus to 
yield, and assumes a bluish-black shade. Ecchymotic patches may 
be intermingled with these, rapidly widening to palm-sized and 
larger areas. The mucous surfaces share in these colors, being also 
infiltrated with effused blood ; and the muco-cutaneous orifices are 
crust-covered and exhale an extreme fetor. Blood may escape from 
the bowels, bladder, mouth, and vagina. Signs of grave systemic 
and visceral complications are always present. Vesiculation, pustu- 
lation, and the typical transformations of the variolous lesions are all 
wanting. In the few cases observed by the author, death has always 
speedily supervened, either from shock, coma, hemorrhagic infarc- 
tion of the lungs, or rapid exhaustion. Intermediate forms between 
hemorrhagic and true variola are described, in which the pustules 
occurring in the latter form of the disease merely fill with blood in 
consequence of accidents possessing a purely local significance. 

The Confluent is another severe form of variola, less malignant, 
however, than that just described. It is characterized by intensity 
of the prodromic fever, which often scarcely abates with the appear- 
ance of the exanthem. The latter is developed in deeply implanted, 
firm papules, closely set together, succeeded by vesicles and pustules, 
which, as they enlarge, fully occupy the entire surface of the integu- 
ment, and accomplish a perfect coalescence. In well-marked cases 
there is scarcely a pin-head sized area of the entire surface of the 
body which is not invaded. The tissues become enormously oedema- 
tous ; the deformity of the face renders the features indistinguishable. 
Hemorrhagic pustules and even patches of a gangrenous pulp may 
be intermingled with the sheets of suppurating surface. Phonation, 
respiration, and deglutition are proportionately impeded or abso- 
lutely subverted by the tumefaction and suppuration of the mucous 



114 DISEASES OF THE SKIN. 

membranes of the respiratory and gastro-intestinal tracts. When the 
patient survives till the stage of desiccation is reached, the body 
presents an aspect as revolting as that ever displayed by a living 
being. A thick, brownish, or blackish-brown mask envelops the 
swollen head, trunk, and limbs; and the odor exhaled from the body 
is intolerably repulsive. All the systemic phenomena are propor- 
tionately grave and accompanied by one or more of the complica- 
tions of the malady, pneumonia, pleuro-pneumonia, albuminuria, 
diarrhoea, various motor and sensory paralyses, subcutaneous furun- 
cles, aud abscesses. The eyes may suffer from pustular and ulcera- 
tive changes in the conjunctiva, cornea, and deeper tissues, with 
resulting inflammation of every grade to panophthalmia, and resulting 
loss of vision. Often the patients, with surprising powers of resist- 
ance, will survive till extensive sheets of crusts have fallen from the 
surface, and then perish slowly in a typhoid condition with low 
remittent or continuous fever. Every such case does not, however, 
conclude fatally. The author has seen children rally from the severest 
form of confluent variola, and enjoy afterward a vigor which illustrates 
well the wonderful recuperative energy of the natural forces under 
the most adverse circumstances. 

Fig. 32. 

c « I. 




Vertical section of pustule at the beginning of pustulation. a, umbilicatiou at the site of an excre- 
tory canal ; b, reticulum within the epidermis ; e, reticulum of smaller meshes containing lymph- and 
pus-globules. (After Rindfi.eisch.) 

Variola is always produced as the result of mediate or immediate 
contagion. It is a disease which is both contagious and infectious, 
being transmissible by volatile emanations from the victims of the 
disease. It is also artificially inoculable. When transmitted by the 
latter process, its period of incubation is somewhat shortened, and 
often its successive manifestations become then less formidable. The 
history of inoculated human variola has, however, received but little 
attention during the last decade, in which the practice has been 



VARIOLA. 



145 



properly forbidden by law. The disease is, to a certain extent, 
transmissible from man to the lower animals, and the reverse. It 
attacks individuals of both sexes and all ages, including the foetus 
in utero, which may be ushered at an untimely hour into the world 
macerated or recently dead and covered with the lesions of variola. 
The disease in the larger cities is decidedly more frequent in winter 
than in summer, possibly because in the colder months the oppor- 
tunities are greater for spreading the contagion in artificially heated 
dwellings where numbers of individuals are crowded together. 
Islanders long unvisited by an epidemic and unprotected by vaccina- 
tion, may suffer equally in the summer season. 

Fig. 33. 







1 HP v ' 



mm 



Vertical section of one-half of an undeveloped pustule, a, old epidermis ; 6, epithelia of rete above 
the alveoli ; c, new formed epidermis; d, alveoli filled with pus-globules; g, flattened and infiltrated 
papillse lying beneath the pustule. (After Auspitz and Basch.) 

The parasitic nature of variola has not yet been demonstrated. 
Coze. Feltz, Baudouin, Luginblihl, Weigert, Hallier, and Cohn have 
recognized microorganisms, both bacteria and micrococci, in the blood 
of variolous patients. None of these have as yet been utilized in 
the production of the disease ; but Cohn 1 regards these parasites as a 
twin race of the micrococcus vaccinae discovered in vaccine lymph. 

The difficulty attending the diagnosis of variola in its prodroinic 
and earliest eruptive stages, from rubeola, has been already mentioned. 
The general demand, indeed, upon the physician for an exact and 
definite diagnosis of every case before its typical development, is 
founded upon an erroneous conception of possibilities ; and the sooner 
this is generally recognized, the better for all concerned. A delay of 
even a few hours will often verify or remove a suspicion, and the 
author is confident that he has seen fully as much mortification on 
the part of the physician and damage to the best interests of the 
patient, result from an error in the one direction as in the other. The 



1 See Mag-nan, loc. cit., p. 411. 
10 



146 DISEASES OF THE SKIN. 

wisest coarse in every doubtful case is to admit the doubt and to visit 
the patient frequently for the purpose of observing the development 
of the disease till that doubt is removed. Typical cases of variola are 
recognized with ease from the character of the symptoms presented. 
Syphilis and acne are always distinguished by the absence of fever 
and their relative chronicity. Two cases of suddenly occurring medi- 
camentous acneiform rash, have come under the author's observation, 
where a diagnosis of variola had been previously made. In each, the 
absence of a prodromic stage and the subjective sensation excited, 
Mere sufficient to point to the nature of the disease when considered 
in connection with the peculiar character of the lesions. 

The prognosis of variola is largely dependent upon the degree of 
protection conferred by previous vaccination. This aside, the age 
and vigor of the patient, the presence or absence of an epidemic of 
severe or mild type, the extent of the eruption, and the character of 
the surroundings of the patient, are elements of prime importance. 
Very young and aged subjects, women pregnant or in the puerperal 
state, and, as Hebra has shown, those who have suffered from a pre- 
vious attack of the same disorder, are all unfavorably related to the 
final result. Confluent and hsemorrhagic forms of the disease are, 
naturally, the gravest. Unmitigated variola is, under the most favor- 
able circumstances, one of the greatest scourges of humanity; and 
as such will probably always destroy a frightful proportion of its 
victims. At the same time, the conscientious physician needs to 
be impressed with the fact, that under the most discouraging circum- 
stances, the patient, disfigured to the greatest extent by an envelope 
of blackened crust, and in a state of extreme physical prostration, 
with many of his bodily functions almost completely suspended, may 
even from the midst of such peril be won back to life and vigor. 
The assiduous attentions of a gentle nurse, guided by the inspiring 
presence aud couusels of a physician who is himself fearless of the 
malady, will often achieve the result. Upon the latter point, it is 
interesting to note, that physicians in active practice who do not 
hesitate to expose themselves freely to the disease in the discharge 
of the duties of their profession, rarely suffer in their own persons. 
In the course of four epidemics, during which the author has had 
the opportunity of observing the relations between many physicians 
and their patients, he has never known one of the former to be 
stricken down in the actual performance of his sacred office among 
the victims of the pest. 

Varicella. 
(Chicken-pox). 

Varicella is a contagious, febrile disorder of benignant and mild character, 
accompanied by a vesicular exanthem. 

The disease has an incubative period lasting for about a fortnight, 
after which there is occurrence of malaise, chilliness, and languor. 
The patients are usually children who may suffer thus from fever of 
a moderate grade lasting from a few hours to two or three days, after 



VAEICELLA. 147 

which defervescence is commonly complete. With its onset, or with- 
out it, the rash appears, first on the head and trunk, in the form of 
rosy macula? or slightly elevated lesious lacking the characteristic 
"shot-like" feeling of the variolous papule. These rapidly become 
vesicular, the lesions being pin-head to pea-sized, limpid, superficial 
in situation, differently shaped and very rarely umbilicated, puckered, 
or "fluted" as in smallpox. They appear in successive crops and 
are often surrounded by a faint halo. Their contents become cloudy 
or lactescent rather than puriform, and desiccate often as early as the 
second day, forming thin, light, superficial crusts. The lesions may 
be abundant in one region, as, for example, over the back or the 
chest ; but are practically never both abundant and geueralized, and 
never confluent. Like the variolous lesions, they extend at times to 
the mucous surfaces of the eyes, mouth, and geuital regions. Occa- 
sionally they are productive of pruritic sensations. Often the course 
of the disease is so mild and the exanthem so slight as scarcely to 
attract attention. Cicatrices result only in places, chiefly the face, 
where the lesions have been subjected to local irritation. 

Diagnosis. — It is well known that a number of German authori- 
ties, following Hebra, have given assent to the doctrines taught by 
the latter that varicella is only a mitigated form of variola. That 
doctrine is offensive to American and English physicians, who in 
practice find it vastly wiser to distinguish carefully and exactly be- 
tween the diseases in question. The settlement of the discussion may 
well be relegated to a date when the probable parasitic nature of both 
disorders can be exactly determined. 

In variola, the invasion period, of relatively fixed limits, the speedy 
transformation of the lesions into minute, firm papules, their early 
appearance on the exposed parts of the face and wrists, the age of the 
patient, the thermic variations, the prodromic rashes, and the speedy 
transformation of the papules into umbilicated vesicles, are all impor- 
tant diagnostic points. In varicella, the trunk usually exhibits the 
greater number of lesions, which appear also in successive crops. 
Beside the characteristics of the cutaneous lesions, the catarrhal symp- 
toms of measles and the sore throat of scarlatina, will point to the 
nature of these disorders. Fox's impetigo contagiosa is to be very 
carefully distinguished from varicella, since the two affections occur at 
times side by side in one hospital ward ; and occasionally the former 
succeeds the latter. The lesions of impetigo contagiosa are often 
larger, generally more persistent, the crusts bulkier, and the patients 
may be of a more advanced age. 

The treatment of variola should, in general, be limited to the indi- 
cations presented in each case. No remedies can be employed which 
have the least power to abort the disease. Kaposi calls attention 
to the striking fact in this connection, that in syphilis, for many of 
whose manifestations mercury is a specific, we find a disease whose 
second incubative period is measured by weeks, and yet neither by 
excision of its initial sclerosis nor by mercurials can the subsequent 
manifestations of the disease be completely prevented. Certainly, no 



148 DISEASES OF THE SKIX. 

specifics arc recognized as of value in variola. The patient should 
be kept in a relatively darkened room with an abundant supply of 
fresh air nf a uniform temperature; and antiseptic solutions should 
be constantly at hand into which all the ejecta are immediately 
received. He should be given ice when this is grateful to the palate, 
cool water ad libitum, and his strength should be sedulously supported 
by a liquid animal diet. The body may be sponged with or bathed 
in cool or tepid water, as often as is grateful to the patieut. In severe 
or confluent cases, the constant immersion of the body in the continu- 
ous warm water bath as practised in Vienna, is followed by the most 
brilliant results in hastening the desiccation and fall of the crusts and 
the subsequent repair. A bath of this character given for merely two 
or three hours in the day, is often of great value. With and without 
these external measures, gargles of chlorate of potash, myrrh, honey, 
or carbolic acid, will be found acceptable to the mouth and palate. 
Indeed, the constant attention of an efficient nurse bestowing assidu- 
ous care upon the mouth, skin, and eyes, may be regarded as an 
essential part of all sound treatment. 

As regards the prevention of pitting, it may be remarked that no 
measures of a therapeutic character will prevent the occurrence of 
a distinct cicatrix whenever pus has eroded or otherwise destroyed 
the integrity of the papillary layer of the corium. Every effort, 
therefore, should be exerted to prevent the extension of the suppura- 
tive process to the true skin. The following are measures which have 
approved themselves to the author as of practical value : first, the sick- 
room should be moderately darkened, and yet amply provided with 
fresh air ; second, a solution of the hyposulphite of sodium (Squibb's 
is superior to the ordinary preparations in the market) should be 
administered night and day in the dose of from fifteen to twenty 
grains (1.-1.3) every three or four hours. Certainly the variolous 
lesions pursue a milder course under this internal treatment, and 
even, in cases, the vesicles shrivel before pustulation is fairly begun. 
Third, the skin of the face should be anointed with a bland fatty sub- 
stance such as vaseline, almond oil, or fresh lard, and over this may 
be laid silk-enveloped compresses, dipped in tepid and weak solutions 
of carbolic or boric acid, or thymol. The author prefers the anoint- 
ing of the surface before the application of the lotion, but, when more 
grateful to the patient, the skin may be constantly moistened with 
the aqueous lotion alone. Here, again, the assiduous attention of the 
nurse is a matter of importance. The author has never employed 
the powder of iodoform topically in these cases, but believes that it 
might be often so used with advantage. 

The edges of the eyelids should be daily anointed with freshly pre- 
pared cold cream. Puncture of the cornea may be required for the 
relief of hypopion. Diarrhoea and other symptoms of visceral de- 
rangement should be relieved by appropriate medication. As a rule, 
the administration of narcotics for the relief of pain is objectionable. 
Throughout all, the strength of the sufferer should be supported by 
a generous use of animal broths or milk ; and in typhoid conditions 
a judicious employment of stimulants may be necessary. 



VACCINIA. 149 

Vaccinia. 
(Cowpox.) 

Vaccinia is a specific bovine fever, accompanied by a vesicular exanthem, 
which can be transmitted to man by inoculation. 

The limits of these pages forbid a discussion of the interesting 
questions which concern the relations of cowpox as it occurs spon- 
taneously in the milch-cow, to human variola. A careful collation of 
the results obtained by the large number of vacciuiculturists of later 
days, renders it clear that it is a matter of great difficulty to transmit 
variola from man to the heifer; that where this rare result is 
obtained, the lymph derived from the lesions on the udder or the 
belly of the latter is liable to produce variola when retransmitted to 
man ; and that spontaneous cowpox alone seems to furnish a lymph 
which is safely inoculable in generations to the human race. 

Of greater importance is it to note here that, either by arm-to-arm 
vaccination, as was formerly extensively practised, or by the use of 
the animal virus which has of late been well-nigh exclusively em- 
ployed in this country, there has been conferred upon millions of 
human beings a degree of protection against variola whose value is 
beyond estimate. In both methods, the lymph is derived originally 
from the female of the bovine race, preferably in the puerperal state; 
and its sources are the vesicular lesions of vaccinia spontaneously 
arising or artificially cultivated about the teats, udder, and adjacent 
parts. The introduction of this lymph into the skin of the human 
subject, is termed vaccination. 

The simple operation of vaccination is performed in many ways, 
but that which especially commends itself to the prudent man is the 
method which eliminates to the largest extent the possibility of trans- 
mitting any other contagious disease than the one intended. With 
this object in view, no better instrument can be devised than a clean 
needle, one which has been properly disinfected and not previously 
employed for any purpose. The skin of the part selected for vacci- 
nation being subjected to slight tension by the left hand, the 
vaccinator should scratch or scrape off the epidermis with the needle, 
held in the right, by a series of parallel and crossed strokes, so as to 
make three or four superficial erosions, at a distance of three or more 
inches apart. Each of these multiplex wounds should have the size 
Of the little finger-nail, and should in no case bleed, but merely ooze 
with serum slightly tinged with blood. At such points the lymph 
is to be thoroughly and slowly rubbed in, whether it be supplied in 
a dry form upon ivory points which have been dipped in the serum 
oozing from vaccine lesions upon the heifer, or be a fluid obtained 
by crushing and dissolving in water the crust taken from the similar 
lesions on the arm of a child previously unprotected and recently 
vaccinated. In public charities, where, for the most part, such pro- 
cedures are practicable. It is usually sufficient to clip a needle into 
the lymph flowing from the arm of the vaccinifer and to plunge it, 
thus charged, once or twice into the part selected for the operation. 



150 DISEASES OF THE SKIX. 

Between the third and fourth days alter a successful vaccination 
of* the unprotected, a light reddish, pin-head sized papule rises at 
each inoculated point. Between the fifth and sixth days, it becomes 
transformed into a translucent, well-distended, occasionally umbili- 
cated vesicle. This, when single, may attain the size of the finger- 
nail. Springing from the multiplex abrasions described above, a 
minute papule usually forms at each point of intersection of the 
crossed lines produced by the scratching with the needle, and the 
subsequent vesicles coalesce, forming thus a compound lesion of 
rather peculiar aspect. It appearsoften as a small coin-sized plaque, 
elevated to the extent of a line or more beyond the general level, 
with a rim formed of numerous discrete or confluent vesicles, which 
in either case arc closely set together. The compound plaque seems 
to develop afteward as a single lesion, its centre being depressed. 
After the ninth day, the fluid becomes opalescent, aud desiccates in a 
reddish-brown crust, which, examined in section by a good light 
after it is completely dried, exhibits a smooth, homogeneous, shining 
appearance, with a color having the shade of amber. 

Fully as important as any of these metamorphoses of this lesion, 
is its rosy-reddish areola, in the absence of which some authorities 
declare that there is not proper protection. It completely encircles 
the compound vesicle in the form of a halo having a diameter of 
several inches, the tissue it invades being often slightly tumid. 
"When the pathological process in the focus of this areola is intensi- 
fied, either as the result of the irritant character of the virus, or from 
extrinsic causes (undue exertion of the vaccinated part), the areola 
may spread extensively down the arm, or over the thigh or leg, and 
eventually cover a dense, brawny, and deeply reddened integument. 
Dermatitis, erysipelas, lymphangitis, adenopathy, and severe grades 
of inflammation of the subcutaneous tissues, may for similar reasons 
complicate the process, which may terminate by central sloughing, 
ulceration, slow repair, and the production of an atypical cicatrix. 
Ordinarily, the subjective phenomena are limited to a mild or annoy- 
ing itching of the vacciuated surface ; in other cases, severe burning 
pain, a feeling of tension, and even sympathetic fever may be aroused. 

The acme of a successful vaccination is usually attained between 
the tenth and the fourteenth days, after which the symptoms of the 
disorder gradually subside, the crust falling, if undisturbed, in the 
course of the ensuing week. When " animal" virus is employed, the 
duration of each of these stages of the disease is usually somewhat 
prolonged. 

The cicatrix, at first slightly reddened or pigmented, gradually 
assumes the dead white appearance of sears in general. When 
typical, it is slightly depressed, circular, not irregular, nor deformed 
by ridges, cords, or bands, and " foveolated," exhibiting a series of 
peripheral pits or depressions, each of which represents the site of a 
former minute vesicle of simple type. There is strong reason to 
believe that the degree of protection is based in part upon the multi- 
plicity of typical cicatrices, and, in view of the rarity of variolous 



VACCINIA. 151 

patients with four such traces of successful vaccination upon the 
person, many are prejudiced in favor of the English method of pro- 
ducing multiple scars. 

The complications of vaccination are due, first, to the character of 
the virus employed; second, to the character of the soil in which it 
is implanted ; and third, to the external accidents to which the vaccine 
lesion is subjected. Respecting the first of these sources, there are few 
■contagious diseases which may be transmitted by vaccination, beside 
syphilis. When this accident occurs, it may be due either "to the 
fact of syphilis in the vaccinifer, or to the use of instruments soiled 
with infectious secretions. It is both asserted and denied, that the 
lymph from a typical vaccine vesicle in a syphilitic vaccinifer, will 
necessarily transmit syphilis, if it be accidentally commingled with 
either blood or the products of inflammation at the base of the pock. 
The demonstration of any such fact requires a mass of evidence 
exceedingly difficult to collect, inasmuch as the stage and intensity 
of the disease in the vaccinifer are elements which cannot be ignored 
in a decision of the question. When thus transmitted, it will be 
remembered that the vaccine lesion may complete its career during 
the incubative period of the initial sclerosis, whose existence at the 
.site of vaccination is commonly declared later by induration, ulcera- 
tion, pigmentatiou, and axillary adenopathy. The occurrence of a 
generalized syphiloderm before the chancre of vaccination is com- 
pletely healed, is ofteu the first symptom to arouse suspicion. Those 
further interested in the subject should study the cases collected and 
admirably illustrated by Mr. Jonathan Hutchinson, 1 of London. It 
should be added, that the popular impression regarding the frequency 
■of this accident is greatly erroneous. The author has treated no less 
than nine physicians for extra-genital chancre of the fingers and 
•eyelids, acquired during the discharge of their professional duties, 
meeting in his entire experience with but two unquestioned cases of 
syphilis transmitted by vaccination. One of these accidents occurred 
to a negro infant, who had a typical initial sclerosis of the arm fol- 
lowing vaccination, with axillary adenopathy, and a subsequent char- 
acteristic generalized exanthem. In all such cases, the possibility that 
the syphilis might be hereditary, and its symptoms simply coincident 
in point of time with those of vaccinia, should not be forgotten. 

Exceedingly dangerous is that virus, however good its early char- 
acter, in which decomposition or putrefactive changes have occurred 
after exposure, in a liquid form, to the action of heat and the atmos- 
phere. Vaccination with lymph thus changed has been rapidly 
followed by fatal results, in consequence of the supervention of 
pyaemia or septicaemia. 

Complications of vaccinia, due to the character or predisposition of 
the tissues in which the virus is introduced by the vaccinator, are 
usually ascribed by the ignorant or prejudiced to the causes just con- 
sidered. Post hoc ergo propter hoc is the sole logic of the uninformed. 

1 Illustrations of Clinical Surgery. Phila., 1875. 



152 DISEASES OF THE SKIN. 

In this way almost all other ills of the human family have been in 
turn ascribed bo " imparities " and "humors" introduced by vaccina- 
tion. The language and arguments used in support of these positions 
have been a- extravagant as they were unreasonable, and have borne 
fruit in the refusal of many physicians of repute to perform vaccina- 
tion, and thereafter to assume the responsibility of all the subsequent 
ailments of the vaccinated. The cutaneous symptoms which may 
thus be awakened are numerous. It will be remembered that the 
contents of the typical vaccine vesicle are auto-inoculable, and that 
thus the scratching of young patients may produce an abundant crop 
of typical or torn vesicles upon the arms, legs, thighs, hands, and 
fingers. Bat vaccination may also awaken in the patient, as 
explained above, a latent syphilis, as also a list of cutaneous disorders 
not contagious in character. Thus an erythema (roseola vaccinia, 
vaecinola, etc.), eczema in many of its forms, and other exudative 
processes may be first aroused in the integument by the turbulence of 
a successful vaccination. 

These rashes may become generalized, and even assume a formid- 
able appearance. They may appear at any time from the second to 
the fourteenth day after vaccination. A scarlatiniform rash, diffused 
or in patches, is described by some authors as occurring in this way, 
accompanied by mild fever, and resembling German measles. Simi- 
larly generalized eruptions, resembling erythema multiforme, psoriasis, 
urticaria, impetigo contagiosa, varicella, and other cutaneous disorders, 
may appear for the first time within the limits named above. They 
usually disappear within a brief time after the vaccine vesicle has 
completed its involution, and may be followed by slight desquamation 
or pigmentation. 1 

Very rarely vaccinia is followed by purpuric symptoms 

Anomalies of the vaccine vesicle are occasionally noted as to its 
shape, career, and resulting cicatrix which it is difficult to explain. 
Thus, the papulo-vesicle may not exhibit an umbilicated centre, or 
may complete its course within unusually short limits ; or a harmless 
ulceration may progress beneath its crust, requiring a week, or even 
more, for complete cicatrization. The so-called " raspberry sore" is 
explained by Robinson as resulting from coalescence of small papules, 
so as to form a pigmented tubercle. The scars resulting from many 
of these irregular and non-protective results of vaccination may in 
each direction form a typical cicatrix, being, on the one hand, small 
palm-sized, deforming, corded, and representative of large tissue-loss ; 
and, on the other, feeble, irregular, and inconspicuous. 

Lastly, the complications of vaccinia due to external accidents of 
the lesion are usually inflammatory in character. The excessive use 
of the vaccinated arm in labor, and of the vaccinated leg in walking, 
standing, and other exertion, may induce, as indicated above, every 
grade of dermatitis, and even ulcerative changes in the site of the 



1 An interesting paper on vaccinal eruptions was read by Dr. Gustav P.ehi'end, before the Dermato- 
logica! Section of the International Medical Congress, in London, August 5, 1881. (See a translation of 
his paper by Dr. Alexander, Arch, of Derm., No. 4, 1881, vol. vii. p. 383.) 



ERYTHEMA SIMPLEX. 153 

inoculation, as a result of the intensity of the process. For these 
accidents rest is essential, with the free use of a dusting-powder over 
the inflamed surface. In exaggerated cases, lotions of lead-water and 
opium may be employed. These conditions are usually relieved 
without difficulty, as soon as the part is put to rest. The atypical 
scar which results, seems to be in such cases as protective as others, 
if only the accident have occurred to a typically progressing lesion 
with distinctly perfect areola. Vaccine cicatrices are to be distin- 
guished in anomalous situations from maculae atrophic*, the scars of 
syphilis, and of other scar-leaving disorders. 

Micrococci have been recognized by Cohn in vaccine-lymph. 
These have been named micrococci vaccinge, but their relation to 
similar organisms discovered in the blood and tissues of variolous 
patients has not yet been determined. Wolff 1 claims to have culti- 
vated these organisms through fifteen generations. Strauss has 
demonstrated their existence in the vaccinal pustules of the calf. 2 

Lipp, of Gratz, reported to the International Medical Congress in 
London, that he had recognized great similarity, if not identity, 
between the micrococci of vaccinia and variola, which he had culti- 
vated to the second generation, but had then been unsuccessful in 
producing inoculation effects. These organisms were always arranged 
in groups of four, or multiples of four. 

Erythema Simplex. 

Gr. kpWrjfia, redness. 

Erythema Simplex is a coloration of the skin in various shades of redness, 
temporarily disappearing under pressure, the lesions differing in size and 
shape according to the extent and degree of the hyperemia by which they 
are induced. 

Hypersemia of the skin, due to increased velocity or amount of the 
fluid in the cutaneous capillaries, results in increased coloration of 
the integument. The shades of this color vary from a delicate pink 
or rosy hue to a dark reddish color. Thus, hyperaemise may be 
diffused or circumscribed, idiopathic or symptomatic, and due to 
active or passive congestion of the vessels. 

Idiopathic Erythema. 

Erythema Traumaticum. — Here the redness is the result of 
friction, rubbing, pressure, scratching, and similar external contacts. 
It is observed, for example, in the part pressed by the pad of a truss; 
in the colored circle left about the leg where a tight garter has been 
worn ; on the sides of the nose where pressure is exerted by a newly 
applied pair of eye-glasses. These traumatic hypersemias are readily 
converted into exudative affections, if the traumatism be long con- 
tinued. Intermittent pressure upon the skin permits restoration of 

1 Berl. klin. Woch., Januan' 22, 1883. - See Magnan, loc. cit. 



154 DISEASES OF THE SKIN. 

the vascular equilibrium, and the skiu responds to the demand made 
upon it, by increasing- in thickness; continued pressure, on the con- 
trary, admits of no such restoration; and the integument finally 
becomes thinner, and yields before the agent inflicting the injury. 
Inflammation resulting in ulceration may finally supervene. 

ERYTHEMA CaL0RICUM. — Solar heat in excess and extremes of 
cold ; very hot and very cold water; and other heat-conducting sub- 
stances, are also sufficient to induce transitory redness of the surface. 
In the erythemata induced by solar heat especially, there is frequently 
an increase in the pigmentation of the surface, as in the production 
of freckles and "tan" in persons whose skins are reddened by the 
sun. The darker, brownish, and chocolate-colored stains of the 
hands and face are thus induced. 

Erythema Venenatum. — A number of chemical substances, 
dyes, and vegetable poisons are also capable of producing transient 
hyperemia of the skin. Among these may be mentioned cantharides, 
capsicum, mustard, aniline, chloroform, ether, arnica, and several of 
the essential oils. 

Erythema Gangrenosum. — Under this title several singular 
affectious of the skin have been described, in which erythematous 
patches appeared and were followed by more or less extensive 
destruction of one or more of the several layers of the skin. T. C. 
Eox, in a description of the appearances in two cases under his 
observation, concludes that these are the symptoms of a feigned 
disease, or one produced artificially for the purpose of exciting 
sympathy, etc. 

Symptomatic Erythema. 

This may be of either active or passive form. A long list of 
physiological and pathological causes operating upon the system at 
large are capable of inducing active symptomatic hyperemia of the 
skin. This may be generally diffused, or occur in surface mottlings 
and markings of various sizes and shapes. Thus, the skin of the face 
may be intensely reddened in a paroxysm of rage; and that of the 
limbs of a teething child covered with rosy maculations in consequence 
of the reflection to the surface, through the medium of the nervous 
system, of the irritation induced by a tooth. In consequence of the 
rosy tint assumed by several of these rashes, they have long been 
termed " roseola," a name which to-day is held to describe a symptom 
rather than a disease. The word "roseola" is still associated in the 
minds of many with the earliest syphiloderm ; but that eruption is 
now designated by the best authors as the erythematous or macular 
syphilide. 

Several of the severer constitutional maladies betray their morbid 
influence upon the central nervous system by a speedy efflorescence 
of this character. A lurid erythema of the axillary or inguinal 
region may precede by several days the eruption of confluent variola. 



ERYTHEMA SIMPLEX. 155 

Cholera, cerebrospinal meningitis, enteric and other fevers are thus 
at times accompanied, preceded, or followed by rashes. A study of 
these is of the utmost importance to the diagnostician. Children who 
are really susceptible to the disease are often supposed to possess an 
immunity from scarlatina, as the symptomatic erythema they pre- 
viously displayed was misconstrued. 

Symptomatic passive erythema is usually characterized by a 
cyanotic, purplish, or darker hue of the integument, resulting largely 
from accumulation in excess of carbonic acid in the blood. The 
temperature of such skins is either normal or below the normal 
standard, as in those cases where gangrene ensues. A long list of 
conditions may be named in which these symptoms may be noted, 
including derangement of the bloodvessels from imperfect innervation, 
•direct pressure, or disease of the heart or vascular walls. 

These erythemas may be either circumscribed in area or general. 
The term "livedo" is applied to circumscribed regions of passive 
erythema. Sometimes the nose, cheeks, fingers, or toes exhibit this 
form of disease. The so-called symmetrical gangrene of the fingers 
belongs to the same category. Cardiac cyanosis, or morbus caeruleus, 
is a name given to a generalized dark blue discoloration of the entire 
surface, due often to continued patency of the foramen ovale. 

Diagnosis. — If an erythema of the surface exists and is manifestly 
unattended by exudative symptoms, the recognition of the condition 
of the skin is not difficult. A more serious problem, however, con- 
cerns the significance of this symptom when it occurs in connection 
with grave constitutional maladies. A high temperature, severe 
lumbar pain, great gastric or intestinal irritability, coryza, and injec- 
tion of the ocular conjunctivae, are symptoms which should always 
put the practitioner on his guard in pronouncing upon the nature of 
an erythema. 

On the other hand, patients in a state of alarm frequently seek 
relief for an idiopathic erythema, of the nature of which they are 
ignorant. Here the locality, contour, and general appearance of the 
eruption, takeu in connection with the history of the case, will usually 
suffice to establish a diagnosis. 

Treatment. — The symptomatic erythemata are usually of such 
trifling significance in comparison with the constitutional disorder by. 
which they are occasioned, that the removal or management of the 
latter becomes of the higher importance. The idiopathic erythemata 
are usually relieved at once by the suspension of the cause. Occa- 
sionally cold water, weak spirit lotions, dilute solutions of carbolic 
acid, or one of the dusting powders may be required. The ordinary 
rubber, adhesive, or lead plaster, may be applied to erythematous 
surfaces where the friction must necessarily be continued (surgical 
appliances, orthopaedic apparatus, etc.), and in those produced by 
constant pressure (nates and sacrum in low fevers or surgical confine- 
ment), it should never be forgotten that the hypersemic is also a 
weakened skin. Here stimulating applications may be needed, alco- 
holic, camphorated, etc., with a view to the restoration of the tone of 
the weakened capillaries. 



156 DISEASES OF THE SKIN. 

Erythema Intertrigo. 

Lat. inter, between ; tcrere, to rub. 

Erythema Intertrigo is an hyperaemic condition of those cutaneous and muco- 
cutaneous surfaces which are in constant apposition, and between which 
there is an hypersecretion or retention of sweat. 

Symptoms. — The erythema which is limited to portions of the 
integument which lie in contact with each other, is subject to certain 
modifications. The sites of such contacts in the human body are the 
axillae, the groins, the cleft between the nates, the inter-mammary 
and infra-mammary spaces in women, the superior and inner faces 
of the thighs, the scroto-femoral and the labio-femoral clefts in the 
sexes respectively, the flexures of the joints, and in especially flit 
individuals, all those parts where the integument is thrown into fleshy 
folds, as about the neck of infants, and even over the crest of the ilia 
in fat women. In these localities the disorder, beginning as an 
erythema traumaticum, proceeds by its irritative effects to stimulate 
the secretion of sweat, which is freely poured out between the adjacent 
folds of the skin, and may there be temporarily imprisoned. The 
surface, heated and reddened, is also somewhat macerated by the 
eifused perspiration ; and the latter, when chemically altered, as it is 
frequently under these circumstances, adds still further to the original 
disorder. The ground is thus well prepared for an exudative process, 
but the disorder may be limited to mere hyperemia with hyperi- 
drosis, and disappear before the supervention of actual inflammation. 

The sensations produced are those of heat and tenderness. When 
the parts in contact are separated, the surfaces are seen to be reddened 
and chafed. Here and there very superficial abrasions of the macerated 
epidermis become evident. One such is always especially significant. 
It is the linear and superficial excoriation which marks the line of 
deepest contact of the two apposed surfaces of the skin at the bottom 
of the angle formed by the two. An offensive odor usually proceeds 
from the part in consequence of the fluid secreted. Fox, of London, 
has called attention to the fact that the secretions of an intertrigo 
stain, but do not stiffen the linen of the patient, and thus differ from 
the serous fluid poured out in an exudative dermatitis. 

Etiology. — The disease is chiefly induced by heat, friction, and 
moisture — these causes occasionally co5perating. The heat may be' 
merely that of the natural temperature of the body, or it may be 
increased by that due to season and climate. The friction also may 
be merely that originating between the surfaces in apposition, or may 
be increased by clothing or other articles worn next the skin. The 
moisture which produces maceration of the epidermis is that origi- 
nating in the perspiratory follicles, their secretion being doubtless 
stimulated by the heat and friction. The interchange of operation of 
these three factors is, lastly, shown by the fact that the friction, if 



EEYTHEMA INTERTRIGO. 157 

severe, is capable of increasing the temperature of the part to which 
it is applied. 

As aggravating causes may be named other physiological secretions 
and excretions, retained in contact with the surfaces affected with an 
intertrigo. Thus, the feces of the infant left in contact with its nates 
upou the napkin ; the urine of the old man with paralysis of the 
bladder, or with " overflow " from prostatic disease ; the milk of the 
nursing woman dribbling over the breast to the infra-mammary 
region ; retained lochial, menstrual, and similar discharges, are all 
efficieut in this regard, and particularly apt to induce that form of 
dermatitis to which the intertrigo then plays a subordinate part. 
Occurring in fleshy persons, these conditions find their most fertile 
field. 

Diagnosis. — The recognition of a simple erythema intertrigo is a 
matter of no difficulty, if regard be had to the exciting and aggra- 
vating causes enumerated above, and to the special localities where 
such hyperemia generally originates. If an eczema or dermatitis 
supervene, the fact will appear from increased subjective sensation 
(usually a severe itching), from an infiltration of the affected integu- 
ment, and from the appearance of those lesions and discharges which 
are significant of these forms of inflammation of the skin. 

The special sites of preference of an intertrigo are those also of the 
disease named by Hebra " eczema marginatum," or ring-worm as it 
occurs upon the parts of the thighs covered by the " reinforced " patch 
in the trowsers of the cavalryman. The disease is properly named, 
tinea circinata cruris, though it is found also about the axillae, but- 
tocks, and groins of both sexes. Here the disorder is, however, of 
the exudative type, and, moreover, is distinguished by a characteristic 
"festooning" of the elevated border marking the advancing limit of 
the disease. The microscope, by revealing the existence of a fungus, 
will, of course, put an end to any doubt. In intertrigo the most 
marked evidence of disease is to be distinguished in the deeper parts 
of the cleft between the two adjacent skin surfaces, while in tinea 
circinata cruris the growth of the parasite is most active at the ad- 
vancing border of the patch, which is, moreover, perceptibly elevated 
above the sound skin. 

Treatment. — Erythema intertrigo is an exceedingly common affec- 
tion of the skin, and occasionally proves of great annoyance to those 
suffering from it. The skill of the youug practitioner is often tested 
early in his professional career by his management of just such cases ; 
and not a little may depend upon the success with which he may be 
rewarded. 

The affected surfaces should be gently cleansed by ablution with 
soap and warm water, and the offensive odor of the secretions reme- 
died by the addition to the water of a weak solution of carbolic acid, 
or the dilute liquor soda? chlorinatse. The parts are then to be care- 
fully dried with a freshly laundried towel or soft handkerchief, and 
afterward one of the dusting powders very thoroughly applied. To 
be of service, these must be quite impalpable, and, if compounded by 



R . Talc, venet. pulv. 


3v; 


201 


Acid, salicyl. 


gr. iij ; 


2 


Magnes. ust. subtil, pulv. 


3jss ; 


5| 


Sig. Dusting powder. 







158 DISEASES OF THE SKIN. 

a druggist, be sifted through millers' fine silk bolting-cloth. The 
articles chiefly used for this purpose are : bismuth, starch, zinc 
oxide, French chalk, lycopodium, and, when an anti-pruritic effect is 
designed, camphor. Combinations of several of these are at times 
effective. The formula of M'Call Anderson is highly esteemed : 

R. Zinci oxid. pulv. ,53s; 161 

( 'amphorae pulv. 3jss ; 6 

Amylipulv. 5J ; 32| M. 

Sig. Anderson's dusting powder. 

The following is the formula for a dusting powder recommended 
by Klamann. 1 



M. 



The "Oswego gloss starch" and the "corn-starch farina" sold by 
most of the grocers in this country, are finely bolted, and answer well 
alone, or in combination with some of the other articles named. The 
chief objection to the starch-containing powders is their tendency to 
form " cakes " or rolls when wetted with sweat, these masses further 
irritating the tender surface of the skin. Such an objection does not 
apply to lycopodium, which not only under the microscope exhibits 
no salient angles, but on account of the oil it contains is not miscible 
with water. 2 

The affected surfaces of the skin must also be separated in order to 
prevent further friction. A thin strip of lint, or the antiseptic cotton 
now in the market, may be used for this purpose ; and must be 
pushed well up to the deeper portions of the cleft where the secretion 
chiefly forms. Occasionally, it will be found useful to anoint this 
absorbent layer with cold cream or vaseline. Where an astringent 
effect is desired, the lycopodium or other dusting powder may be com- 
pounded with tannin, alum, or similar substances. The list of lotions 
may be also at times consulted with advantage. Thus, cologne water, 
weak spirit lotions, tannin, and aromatic wine, or carbonate of mag- 
nesium, may each be serviceable. Lastly, the charron oil (equal parts 
of lime-water and linseed-oil), spread thickly upon linen, will possibly 
give more relief than the other articles named ; the chief objection to 
it being the consequent soiling of the patient's clothing. 

» Hebam. Kalend., Obstet. Gazette, March, 1882. 

- Unna's salve muslins and pastes will be found effectual and neat applications in many forms of 
intertrigo. 



ERYTHEMA MULTIFORME. 159* 



Erythema Multiforme. 

Erythema Multiforme is an exudative disease of the skin, in which appear flat 
or elevated lesions of an erythematous type in various forms, the exanthem 
being at times symptomatic of constitutional derangement. 

Symptoms. — In this affection, which is usually of symmetrical de- 
velopment, erythematous maculae, flattened papulse, and even large 
flat nodosities, very rarely vesicles, occur, usually upon portions of 
the extremities, the forearms, the legs, and the dorsum of the hands 
and feet. The eruption, which is much more generally recognized in 
clearly defined patches, usually commences with pin-head to finger- 
nail sized macules of a darkish-red shade, losing their color under 
the pressure of the finger, which in the course of some hours exhibit 
tumefaction in various degrees, producing thus the papules, tubercles,, 
and nodes already described. The disease may persist for but a few 
days, but in severer grades it lasts for several weeks. In the height 
of the exudative process, there is usually an efflux of the coloring 
matter of the blood into the skin which is the site of the several 
lesions ; and thus are produced the singular shades of reddish-black, 
purple and red, blue and red, yellow and orange, which are so char- 
acteristic of simple bruises of the extremities when the injury has 
been sufficient to cause extravasation of blood. The lesions occur in 
various shapes, sizes, and shades, and a number of names have been 
used to designate their several appearances, which require explanation 
though they are without any practical value. 

Erythema Annulare is characterized by central paling of color 
and peripheral extension of the erythematous patch, in the form of a 
ring. 

Erythema Figuratum occurs in gyrations formed by coalescence 
of two or more annular circles. 

Erythema Iris (Herpes Iris) is the result of successive new ery- 
thematous centric colorations, by which at times several differently- 
shaded concentric rings are formed. 

Erythema Marginatum is that form in which a distinctly ele- 
vated and defined marginal band is left as the sequel of an erythe- 
matous patch. 

Erythema Nodosum is regarded by several authors as a distinct 
affection. In it the characteristic lesions are of the dimensions of 
semi-globular pea to fist-sized tumors, pale red to livid blue in color,, 
tender upon pressure, exhibiting in their involution the variegations 
of hue already described. They occur at times, not only in the locali- 
ties named above, but also upon the trunk and face. Though occa- 



160 DISEASES OF THE SKIN. 

sionallv becoming so soft to the touch that fluctuation may seem to 
be present, they never terminate by .suppuration. 

Erythema Papulatum (or Papulosum) and Erythema 
Tuberculatum (or Tuberculosum) are those forms in which 
-occur respectively lesions of a papular or tubercular type. 

Erythema Urticatum is that form in which there is severe 
itching, and, as a result, scratching of the lesions, with crusts of dark 
dried blood at the summit of each. This crust is surrounded by the 
light red or bluish-red, flattened or elevated patch characteristic of 
the disease. 

Erythema Yesiculosum and Erythema Bullosum are rare 
ami exceptional forms where the exudation is sufficient to raise the 
horny layer of the epidermis into larger or smaller, serum-containing^ 
chamber's. These may be, as regards the erythematous patch, of 
central or peripheral situation; and may crown the summit of papule 
or tubercle. The fluid is usually removed by absorption, and is rarely 
set free by rupture of the vesicle or bleb. 

Robinson 1 describes definitely an Erythema Diphtheriticum, 
which is a rash of septic diphtheria. The early eruption is a diffuse 
erythema of the skin of the chest or of the belly, light red to pale red, 
mottled, scarlatiniform, or punctate, non-pruritic, disappearing under 
pressure, unaccompanied by fever, and vanishing in one or two days. 

The rash of septic diphtheria occurs only after several days of the 
disease, and is a limited or generalized erythema. It begins as pin- 
head or larger sized erythematous maculae, each of which spreads at 
the periphery, and pales in the centre, by which process rings are 
formed. The latter increase till a diameter of several inches is 
attained. While these erythematous rings with clearing centre and 
red, elevated rims are enlarging, new spots continue to form, till the 
eruption has all the features of a multiform erythema. Gyrate and 
figured forms result from coalescence of lesions. Occasionally, the 
centre of a ring is cyanotic. The eruption does not itch. In fatal 
cases it persists till death. 

A number of medicaments, when ingested or externally employed, 
are capable of producing eruptions identical in appearance with the 
lesions of erythema multiforme. For descriptions of these the reader 
is referred to the chapters devoted to dermatitis medicamentosa and 
dermatitis venenata. Quinine, the iodine and bromine compounds, 
arsenic, belladonna, chloral, salicylic acid, and other substances, are 
often responsible for these symptoms. 

The name, multiforme, given to this disease by Hebra, is justified 
by the singular diversity of lesions which it displays. These are 
remarkable not merely for their variety, but for their occurrence in 
such variety both simultaneously and successively, and for their rapid 
change from one type to another. 

i Jonrn of Cutan. and Yen. Dis., 1883, p. 83. 



EKYTHEMA MULTIFORME. 161 

The subjective symptoms, save in the urticarial form of the disease, 
are usually of a trifling character. The slight sense of heat and 
burning awakened by the lesions is altogether out of proportion to 
the extent of development of the latter. 

The symptoms, however, indicative of a general disturbance of the 
system may be of a marked character. General malaise, fever, inap- 
petence, pharyngeal inflammation, chills, severe gastro-intestinal 
disorder, rheumatoid involvement of the articulations, and even 
organic changes in the heart (valves, endocardium, and pericardium), 
lungs, and kidneys (Kaposi), have all been noted as coincident or 
causative phenomena. In many of these cases it is clear that the 
exanthem belongs to the list of symptomatic erythemata, and is of 
insignificance in comparison with the grave general condition. With 
these exceptions, however, the prognosis is in general quite favorable, 
as the disease may terminate in a few days, and rarely exceeds a 
month in duration. 

Occasionally the mucous membranes are affected to a disagreeable 
or even painful extent. Thus a sudden tumefaction of the uvula 
may supervene upon the cutaneous symptoms, even in cases sufficient 
to impede respiration ; or the lining membrane of the larynx be 
involved, and the resulting aphonia in various degrees persist for two 
or three days. 

Etiology. — ''We are in a state of complete ignorance as to the 
cause of these erythemata " (Hebra). We simply know that the 
affection is more common in the spring and autumn ; that it occurs 
in the young or in the early periods of adult life ; that the papular 
and tubercular forms are more common in men, and the nodose forms 
in women ; and that in many cases it occurs in those who are affected 
with rheumatism. There can be but little doubt that its etiology 
includes a list of varying and widely differing causes. The author 
has seen severe manifestations of the disease in a young woman with 
extensive ulceration of the cervix uteri. Tilbury Fox noticed its 
frequency in young servants brought to town from the country. It 
is not rare in young female immigrants who have recently made a 
" steerage " passage to this country. 

Pathology. — Erythema multiforme is essentially an hy perse mia of 
the integument which, under certain obscure influences, advances 
more or less rapidly to the stage of a mild grade of inflammation 
with consequent exudation. If, with Landois and Lewin, it be 
accepted that the process is the result of vaso-motor nerve influence, 
it cannot be determined whether these nerves are irritated at points of 
origin or distribution. In the case of erythema nodosum, Hebra 
advances what he admits to be an hypothesis, in saying that the 
morbid process is essentially an inflammation of the lymphatic 
vessels. In some cases it is evident that there is extravasation of 
blood from the vessels into the skin of the affected parts. 

Leloir 1 discovered in the papules, tubercles, and bulla? of the 

i Bull, de la Soc. Anat., 1884, p. 294- 
11 



162 DISEASES OF THE SKIN. 

erythemata, only the phenomena of hyperemia and exudation limited 
to the corium and subcutaneous tissue ; and Villemin 1 simply con- 
firms these diets. 

Diagnosis. — Erythema multiforme is always to be carefully distin- 
guished from the traumatisms producing bruises, especially upon the 
lower extremities. This is a point which may have an interesting 
bearing upon certain medico-legal questions, especially in the case 
of young children. 2 The tendency of the disease here considered to 
symmetrical arrangement upon the two sides of the body; the 
occurrence of lesions evidently (latino- from several periods, where 
successive crops appear ; and the absence of all history of external 
injury, will usually suffice to establish a diagnosis. Among the pre- 
cocious affections of the subcutaneous connective tissue in syphilis, 
Mauriac has described a lesion resembling somewhat the symptoms 
of erythema nodosum ; but in such cases, and especially in women, 
mucous patches of the vulva, anus, or mouth, with coincident adeno- 
pathy, would point to the real nature of the disease. 

Irecdment. — As the disease under consideration progresses naturally 
to a favorable termination within the course of a few weeks, the duty 
of the physician is usually limited to the question of diagnosis merely. 
He should remember that the larger lesions seen in erythema nodosum 
never suppurate; and thus be not tempted to open them with a 
lancet. Local treatment is rarely called for; and in any case should 
be restricted to the application of hot or cold water, as found most 
grateful to the patient, with possibly the use of a weak lead lotion. 
Internally such medication should be employed as is indicated by 
the general condition of the patient. Iron, quinine, strychnia, and 
the dilute hydrochloric acid will be found beneficial in many cases. 
Constipation and indigestion are to be corrected by appropriate 
measures. When the disorder is evidently purely symptomatic, the 
internal treatment is to be directed to the general condition present. 
In rheumatic cases, the indications for such treatment are clear. 
When the erythema produces extensive oedema of the uvula, incisions 
may be requisite to prevent dyspnoea and dysphagia. 

Prognosis. — It will be gathered from what has preceded, that the 
prognosis is always favorable. The fatal cases reported are usually 
those where the result was due to grave constitutional conditions, and 
where the erythema multiforme was an insignificant feature of the 
malady. The disease may relapse in susceptible individuals at those 
periods of the year when it is most frequently observed. 

1 Gaz. Hebdom., 1886, Nos. 22, 23. 

2 Since this paragraph was written, the author, in conjunction with a number of other physicians, 
was summoned as a witness in a case where both parents of a lad who exhibited the lesions of poly- 
morphous erythema, and who died suddenly, were charged with beating their child to death. They 
were exonerated on the basis of the evidence of the experts. 



UKTICAEIA. 163 

Urticaria. 

Lat. urtica, the nettle. 

Urticaria is an exudative affection of the skin in which appear ephemeral, 
whitish, or rosy-tinted wheals surrounded by a reddish areola, giving rise 
to an intense pruritus. 

Symptoms. — This disorder, popularly known as the " Nettle-rash" 
or the " Hives," may be ushered in by constitutional symptoms, such 
as inappetence, malaise, cephalalgia, or mild pyrexic symptoms lasting 
for a few hours or even for a day or more. 

With, and often without, such prodromic symptoms the eruption 
suddenly appears in the form of wheals upon the surface, which 
frequently disappear with equal rapidity, leaving behind no traces of 
their existence save a slight and transitory hypersemia of the affected 
spot. The lesions may be as small as a finger-nail or a coffee-bean, 
and are usually of this size ; but in certain rare instances " giant 
wheals" are seen, large tomato-sized projections or flat elevations of 
broad areas of the integument, covering the greater part of the belly 
or the buttock. In color, they are either rosy-red or whitish ; and 
are usually surrounded by an hyperaemic areola. They may be 
isolated and few ; or numerous and closely packed together ; may 
even coalesce so that individual lesions are scarcely recognizable. 
They are usually firm and semi-solid to the touch. Rarely the horny 
layer of the skin is raised in fluid-containing lesions by the sudden 
effusion of serum beneath. In contour, they are roundish or oval- 
shaped ; but a variety of curious outlines may result from the irregu- 
larity of their development. Concentric circles, lines, bands, and even 
figures, are in this way produced. The finger-nail drawn across the 
unaffected portions of the skin, in a patient with urticaria, will often 
produce a linear wheal of extent corresponding to the line of irrita- 
tion. It is said that in this way the so-called " medium" with a 
sensitive skin exhibits written characters upon the surface of his 
body. 

The subjective sensations induced by these lesions are distressing 
in various degrees, according to the susceptibility of the individual. 
Every grade of pruritic burning, tickling, crawling, pricking, and 
especially stinging sensations are thus engendered. The efforts of 
the patient to secure relief by scratching, not only serve still 
further to develop the eruption, but to irritate, tear, and otherwise 
wound those lesions already in full evolution. In this way the 
serous effusions are produced at the summits of the wheal ; and in 
this way, also, the lesions really transitory in their course- may be 
changed to more persistent, deeply colored, flat, lenticular papules. 
Where the skin is delicate and thin, as that of the lids and prepuce, 
considerable oedema may result. 

All parts of the body may become affected, and this irrespective of 
age and sex, though children are particularly liable to the disease. 



164 DISEASES OF THE SKIN. 

There are few very young children with skins unwashed for an entire 
month, who will not exhibit urticarial symptoms, if there be an added 
irritation of the surface. 

The lesions may be numerically few, or so numerous as to cover 
the entire surface of the body. Though more frequently acute in 
course, they may recur frequently from apparently insignificant 
causes, or even become chronic. In many cases trivial, the disease 
may become so aggravated as to make the largest demands upon the 
skill of the physician. 

The rapidity of appearance and disappearance of the lesions visible 
upon the skin is a characteristic feature of the disease. In some 
instances but a few moments are required after the operation of an 
efficient cause, to develop a large number of closely packed wheals 
upon the skin. Even while these are under inspection, it can be 
noted that there is a change in individual lesions, some fading or 
completely disappearing, while others are newly developing. 

A number of names have been employed to designate the several 
external peculiarities of the lesions as they are presented to the eye. 
Thus U. Annularis occurs in rings ; U. Figurata, in gyrations from 
union of several lesions or patches of lesions ; U. Vesiculosa and 
U. Bullosa, where there is a vesicular or bullous development at the 
summit of the lesion ; and U. Papulosa (or Lichen Urticatus), where 
there is a combination of the features of the wheal and the papule, 
the lesions being usually rape-seed to coffee-bean in size, and covered 
with blood crusts where their apices have been torn in _ scratching ; 
U. Tuberosa, where " giant " wheals occur, some attaining the size 
of a hen's egg ; U. Hemorrhagica (Purpura Urticata), where the 
urticarial element is developed in a lesion produced by cutaneous 
hemorrhage ; and U. Evanida, or Perstans, where there is respec- 
tively a rapid or slow process of involution in the characteristic 
symptoms. 

Urticaria Pigmentosa. 

In this form of the disease, characteristic wheals in young subjects 
are succeeded by peculiar pigmentations of the surface in dark-brown, 
greenish-yellow, or chocolate-tinted spots, which persist from the date 
of one eruption to another. The skin is highly irritable, and the 
most trifling causes are sufficient to induce an attack. In Morrow's 
case 1 the mere removal of the clothing and exposure of the skin of 
the little patient to the air were sufficient, at the time the author had 
the opportunity of observing the phenomena, to produce an abundant 
crop of wheals over the surface. The pigmentation in these cases is 
probably due merely to the extraordinary sensitiveness of the integu- 
ment, whereby repeated and rapidly repeated exudations occur in the 
skin, and the "resulting maculations are proportioned in depth of color 
to the frequency and intensity of the process. 

Four cases of this disease were exhibited at the International 

1 Archives of Dermatology, Jan. 1879. 



URTICARIA. ' 165 

Medical Congress iu London in 1881, by Mackenzie, Cavafy,and Fox; 
and others have been reported by Nettleship, JBeatty, and Crocker. 

In a case where the lesions of this singular disorder were examined 
by Pick, microscopically, hemorrhages were recognized in the lesions. 

Baker 1 reported, a case of Urticaria Tuberosa characterized by the 
presence of persistent, yellowish-red tubercles in various parts of the 
body which proceeded to ulceration. The parts most affected were 
the knuckles, elbows, and ears. These tubercles are said to have 
begun in a manner similar to that which characterizes the onset of 
evanescent urticarial wheals and tubercles. A somewhat similar case 
was observed by McCall Anderson. 2 

Urticaria, like erythema, may be either idiopathic or symptomatic ; 
and in either, the urticarial condition may underlie or be superim- 
posed upon almost every elementary lesion noted in the integument. 
Its lesions may complicate (or be complicated by) the macule, papule, 
tubercle, vesicle, bulla, and pustule. It may spring from an excoria- 
tion, or result in a fissure. It is common in traumatisms, and is a 
prominent symptom in the skin bitten by insects, reptiles, and the 
domestic animals. 

Etiology. — Idiopathic urticaria always results from the action of 
external irritants. The enumeration of these would require a recital 
of all the external agencies which are capable of irritating the skin. 
Prominent among them are the bites and stings of mosquitoes, lice, 
fleas, bed-bugs, flies, gnats, wasps, caterpillars, and bees. Contact 
with certain species of the jelly-fish is said to be also effective. The 
wounds thus inflicted usually excite a stinging or burning sensation, 
by which the patient is excited to rub or scratch the part. Then 
a wheal is rapidly formed in the site of the injury, and the irrita- 
tion thus set up is conveyed to other parts of the skin in the vicinity, 
so that, especially in children, a single traumatism by an insect may 
excite an urticaria covering a much larger area. Many medicaments 
operate similarly, and it should be added that some of them, though 
applied externally without toxic effect to the mass of men, may pro- 
duce urticaria in exceptional cases. Thus a common flaxseed poul- 
tice when made to cover but a small portion of the body has 
produced violent symptoms of the disease under consideration. The 
irritant action of the nettle (U. urens and U. dioica) has given the 
malady its name. Climatic influences, more particularly those in 
which the surface of the body is exposed to cold air, are very efficient 
in the production of urticaria, as also of bronchial asthma, with the 
symptoms of which the disease under consideration may often coexist 
or alternate, in the case of adults. Mechanical violence, the applica- 
tion of leeches to the surface, and surgical traumatisms may also 
induce the disease. 

Symptomatic urticaria is chiefly of the variety named by authors, 

1 Lancet, Aug. 1881, p. 153. "~ Brit. Med. Journ., Dec. 8, 1883. 



166 DISEASES OF THE SKIN. 

ah ingestis, since it most frequently results from medicinal or dietary 
articles taken into the stomach. Of the latter class may be named 
eggs, cheese, pork, sausage, coffee, tea, cocoa, and confectionery ; 
crabs, lobsters, clams, caviar, and several species of fish-roe, oysters, 
and fish generally ; strawberries, cucumbers, skins of grapes, nuts, 
dates, raisins, almonds, figs, prunes, gooseberries, and raspberries; 
canned fruits, meats, and vegetables; oatmeal, peas, beans, onions, 
garlic, and " corn ;" pickles, sauces, honey, mushrooms, pastry, 
salads, and spinach. Vinegar, champagne, beer, and alcoholic 
beverages in general are capable of inducing a similar effect. 

Among the medicinal articles capable of inducing urticaria may 
be named the balsams, the turpentines, quinine, glycerine, chloral, 
valerian, arsenic, hyoscyamus, cinchonidia, salicylic acid and the 
salicylates, senna, santonine, and opium and its alkaloids. 

In the case of children and infants, a severe urticarial efflorescence 
may be provoked by any undigested morsel of food, or indigestible 
material of any sort, which may have been passed into the stomach. 
Thus a bit of orange-peel, or fragment of potato-paring, or the skin 
of grapes, may be discovered to lie at the root of the trouble. In 
the case of adults also who have suffered from repeated attacks of 
urticaria, and have a fully developed sensitiveness of the gastro- 
intestinal tract, almost any unusual alimentary substance, if ingested, 
may induce a return of the disagreeable symptoms. 

It must be borne in mind that this undue sensitiveness to the effect 
of ingesta or external irritants is often an idiosyncrasy peculiar to the 
individual either on special occasions or at all times, and that, given 
this susceptibility, the effect is often great with a relatively insignifi- 
cant etiological factor. Thus one may see cases in which a teaspoonful 
of beer, one grain of quinine, the smallest fragment of cheese, and 
but a single strawberry will not only induce an urticarial rash of 
such extent as to cover the greater part of the surface of the body, 
but will do the same on every occasion when the articles named 
are swallowed in the quantities given. This, it is important to re- 
member, is in general characteristic of the medicamentous eruptions. 
The a priori reasoning, that the greater the quantity of the toxic 
agent applied or swallowed, the graver the effect, may lead to gross 
errors. It should always be remembered, in seeking the explanation 
for an urticarial rash, that the smallest amounts of apparently inno- 
cent substances may be responsible for the largest annoyance. 

Other causes of urticaria may be cited, such as moral emotions 
(fear, shame, anger) ; gastro-intestinal disorders, where ingesta play 
no part; intestinal parasites; malaria; the exanthematous fevers, 
particularly in their prodromal stages: disorders of the uterus, kid- 
neys, and nervous centres; pregnancy, dentition, and the irregu- 
larities attending the menopause ; and, lastly, the following special 
diseases : asthma, pemphigus, prurigo (of Hebra), rheumatism, and 
purpura. 

Pathology. — The wheal of urticaria is produced by an interchange 
of play between bloodvessels, muscles, nerves, and tissues, under the 



URTICARIA. 167 

operation of a principle which the French characterize as the choc en 
retour. There is, first, most probably under the influence of the vaso- 
motor nerves, a clonic spasm of the capillaries in a limited area of the 
derma, by which an acute oedema is produced with some serous exu- 
dation. The rapidity with which this occurs is greater than that 
with which the tissues of the vicinage can accommodate themselves 
to it either by imbibition or more diffuse tumefaction, and there 
results a counter-pressure upon the affected capillaries, by which their 
lumen is still further restricted. As the wheal is not a purely fluid- 
containing nor yet an entirely solid lesion, but is semi-fluid in con- 
sistency, the mechanical pressure is greatest at the centre and least at 
the periphery. Thus is explained the white and relatively bloodless 
appearance of the centre of certain wheals, and their rosy or reddened 
outer border. It is confirmed also by the fact that generally the 
most acute lesions, those springing into view most rapidly, are chiefly 
characterized by this whitened centre, while those more indolent or 
even chronic in their career, have been less subject to the inter-play 
of the forces described above, permit of more general vascular injec- 
tion, and have a light crimson or even at times a dull red centre. 
Wheals have been excised and examined microscopically by Neumann, 
Poncet, and others, with the result of discovering merely evidences 
of infiltration. According to the last-named author, the lymphatic 
vessels are also choked with " lymph clots." Rohe 1 explains the 
occurrence of the wheal by supposing that certain sensitive nerve- 
fibres of the skin possess also a vasomotor function. 

The process described, occurring as an epiphenomenon after the 
traumatisms or other cutaneous lesions enumerated above, merely 
adds its characteristic symptoms to those previously apparent. 

Diagnosis. — The diagnosis of typical urticaria is so readily made 
that the disease is often recognized before the attention of a physician 
is called to it. As usual, the atypical cases are those in which con- 
fusion may arise. The chief points to be remembered are : the rapidity 
of evolution of symptoms, their ephemeral duration, and the char- 
acteristic sensations they awaken. The action of the animal parasites 
and insects not parasitic should not be overlooked, and the rash be 
closely examined for the minute wounds inflicted in this way, often 
covered with a minute pin-point to pin-head sized dried " blood- 
scale." The various forms of erythema papulatum, tuberculatum, 
and nodosum are liable to be mistaken for urticaria; but this is in 
many cases inevitable, as the intermediate forms between the two 
disorders are with difficulty assigned to either category. Absence of 
marked subjective sensations and persistence of lesions would 
generally imply the existence of an erythema, while marked preva- 
lence of these symptoms would properly decide in favor of urti- 
carial disease. 

In many cases the physician is consulted by a patient who gives a 
history of well-nigh intolerable distress at night or at other capriciously 

i Maryland Med. Journ., May 15, 1881. 



1^8 DISEASES OF THE SKIN. 

selected hours, who repeatedly and vainly endeavors to exhibit the 
lesions as they appear upon the .-kin. Being- examined on occasions, 
scarcely a trace oi cutaneous disorder is manifest. Here the practi- 
tioner has practically to decide upon the character of an eruption he 
never sees. The task is rarely a difficult one. No other than the 
urticarial eruption behaves in this fashion. Occasionally the physi- 
cian will discover delieate, rosy, or deeper stained mottlings of the 
surface where the wheals have been but are not. At times also he 
will succeed, on the flexor aspect of the forearm, or in some situation 
where the skin is equally delicate, in producing the appearance of one 
,»r more tvpical lesions by the aid of his finger-nail in scratching or 
rubbing. " These cases are more frequently of the chronic or at least 
relapsing class; and the victims of the disease may have a charac- 
teristic fades, a worn look from loss of sleep or mental emotion. One 
is apt to discover in this class those who are mourning over the death 
of relatives, loss of property, separation from home and friends, and 
those harassed by anxieties. 

The several lesions of erythema are larger than those ot urticaria, 
and do not develop from characteristic wheals ; in erythema multi- 
forme, the lesions are far more persistent in type, and do not provoke 
the characteristic subjective sensations of urticaria ; in erysipelas, the 
redness is characteristic aud the swelling more diffuse. 

Treatment. — Many cases of acute urticaria demand no treatment. 
The physician is summoned for a diaguosis. The patient and his 
friends are alarmed bv the dread of variola or other severe affection, 
and learning that perhaps a pickled cucumber is alone responsible for 
the disorder, they wait with equanimity for the conclusion which is 
always reached." Fortunately, the unusual, severe, and relapsiug 
forms rarely begin with acute symptoms. 

Naturally the first indication to be observed is the removal of the 
cause, and "this, if possible, accomplished, the exclusion next ot all 
aggravating agencies. The discovery of the cause, at times readily 
effected, is often the most serious problem which is presented An 
exhaustive and minute examination of the person aud history of the 
patieut, a study of his food, drink, medicine, regime, clothing, sleep- 
ing apartment,' habits, occupations of life, and mental state, are here 
essential. When the disorder is recent, and is an urticaria ab ingests, 
a brisk emetic or cathartic may rid the stomach or bowels of offending 
matters. This done, it should be borne in mind that an idiosyncrasy 
of the patient may at this moment render the skin peculiarly sen- 
sitive to the action of other ingesta, and the diet, tor a tew days 
certainlv, should be carefully prescribed. In many cases the alkalies 
are indicated bv an acid condition of the stomach, and then the 
preparations of sodium, potassium, and magnesium are useful. Lax- 
atives, such as rhubarb, magnesia, the cathartic mineral waters, and, 
in the ease of children, small doses of castor-oil, are frequently 
indicated when there is no suspicion of irritating ingesta. At other 
times there is marked atony of the digestive organs, when the mineral 
acids, the bitters, and the ferruginous tonics may be needed. Again, 



URTICARIA. 169 

lactopeptine, pepsine, or the subcarbonate or the subnitrate of bismuth 
may be exhibited with advantage for the relief of the indigestion 
which may be the prominent feature of the attack. 

Other remedies found useful in the internal treatment of urticaria 
are sulphurous acid in drachm (4.) doses three times daily in sweetened 
water (Da Costa) ; copaiba ; strychnia (Guibout) ; the arseuiate of 
sodium, employed by Blondeau in doses from one-thirtieth (0.002) to 
one-fiftieth (0.0013) of a grain; the fluid extract of ergot in half- 
drachm (2.) doses (Morrow); the sulphate of atropia, given by 
Schwimmer in doses of one-sixtieth (0.001) of a grain ; and the sali- 
cylate of sodium in scruple (1.33) doses. The last named drug has 
been highly praised by a number of writers. It is often given in 
one grain (0.06) doses every hour. Pilocarpine, or the fluid extract of 
jaborandi, is known to produce at times a powerful effect in relieving 
surface congestions of the skin, by means of the excessive hyperi- 
drosis which it occasions, and in proportion to which it may become 
daugerous. 

Schwimmer endorses the following formula for this affection : 



R. Atropine sulph. gr. 

Glycerin. j 

Aq.dest. j 

Gum. tragacanth. q. s. 

Ft. pil. No. xx. 



aii 3ss ; 



01 

M. 



The treatment of a symptomatic urticaria should have regard also 
to that disorder of the viscera or general system to which the cutaneous 
symptoms may be attributed. The uterine complaint of a woman 
may require appropriate treatment, as also the diabetes of the patient 
with an affection of the kidneys. Quinine is, of course, indicated in 
periodical attacks, but its action in exceptional cases as a direct cause 
of urticaria should not be forgotten. The same, to a greater extent, 
is true of arseuic, the bromide and iodide of potassium, hydrate of 
chloral, and gelseminum. The larger number of patients are best 
treated without the employment of these drugs. 

In the local treatment of urticaria, which is chiefly intended to 
assuage the disagreeable sensations experienced in the skin, the 
greatest diversity exists in the methods employed. This is to be 
largely explained by the fact that a similar difference is to be noted 
in the relief experienced by different patients after the application of 
the same medicinal agent. Thus cold and hot water baths, baths 
medicated by marine salt, aromatic vinegar, alcohol, cologne, camphor, 
the alkalies, and sulphuric ether ; compresses dipped in such solutions 
and laid over the part affected ; douches and vapor baths will, any of 
them, in the case of some individuals produce a marked alleviation 
of symptoms ; and in others be either inoperative or actually serve to 
aggravate the symptoms in the highest degree. Hebra asserted that 
several of the baths named above are quite useless, while Kaposi 
recommends cold lotions medicated with aromatic volatile substances. 
Fox prefers alcohol, or cologne water to which benzoic acid has been 
added, dabbed over the part, and permitted to evaporate. Hillairet 



170 DISEASES OF THE SKIN. 

and Gaucher employ in a similar way a solution consisting of one- 
third of ether and two of warm water. 

The alkaline hath should contain the carbonate of sodium, the bi- 
boratc of sodium, alum, or the bicarbonate of potassium, either singly 
or in combination in the strength of about six ounces (192.) of the 
salt to thirty gallons of water. One or two ounces (32.-64.) of the 
sulphuret of potassium may be substituted for these. The water is 
made demulcent by the addition of starch or gelatine, or by squeezing 
into it a bag of muslin containing bran. When it is desired to 
employ the acid bath, half an ounce (1G.) of either the muriatic or 
nitric acid Ls added to the quantity of water given above. The bath 
of this size may also be medicated with one drachm (4.) of corrosive 
sublimate; or this drug may be used as a lotion in the strength of 
from one-fourth (0.0016) to one-half (0.0033) a grain to the pint. 
Carbolic, benzoic, salicylic, boric, dilute hydrocyanic, and dilute 
nitric acids in weak solution, are also employed with advantage in 
some cases. Other external applications are thymol, carbonate of 
ammonium, bromide of potassium, ether, chloroform, and chloral- 
camphor in the strength of half to one drachm (2.-4.) to the ounce (32.) 
of ointment. This last is prepared by rubbing together equal parts 
of camphor and chloral till a semi-liquid substance results. It is an 
antipruritic remedy of some value, but will increase the uneasy sensa- 
tions produced, if not largely diluted. 

In other cases the oily or fatty substances will give more prompt 
relief, especially if the eruption has been much irritated by scratching 
and tends to persist. Among them may be named the linimentum 
calcis of the pharmacopoeia, and cold cream to which have been 
added a few drops of the fluid extract of grindelia robusta. 

Mention should also be made here of the dusting powders which 
the reader will find described in the chapters relating to general 
therapeutics and the erythemata. They are the most cleanly of all 
external preparations in urticaria, and are often the only local 
measures required. With internal medication, as each case may sug- 
gest, the practitioner will be careful to note that the clothing of the 
patient is of a character that will not aggravate the eruption, that 
sleep is secured without an excess of bed-covering, and that places 
where the temperature is for any reason elevated are carefully avoided, 
such as the proximity to a fire-place or drop-light, the opera-house, 
the kitchen, etc. 

Among the Germans, sulphur, naphthol, and tar salves are 
employed in the management of the disease. 

One of the most effective and trustworthy of local applications in 
severe urticaria is a starch solution. The starch is first mixed with 
ci. Id water, and then boiled till the solution is of the consistency of 
thin mucilage. To each pint of this a drachm (4.) of the oxide of 
zinc, and a couple of drachms of glycerine (<S.) are added before 
ebullition is completed. When cool, and applied to the surface, this 
often gives prompt relief. 

Such is the empirical treatment of urticaria. It will be seen to be 



DEKMATITIS. 171 

founded upon no rational method of procedure, and this because the 
very capriciousness of the disease demands and secures relief in one 
instance by a treatment which should be reversed in another. It 
must be admitted that cases occur in which all treatment seems abso- 
lutely valueless, often really injurious to the patient. These cases 
will usually be found to be of the relapsing or chronic type. The 
subjects of this form of disease are often plunged in morbid mental 
states ; dreadiug by day the exacerbations of the night ; brooding 
over misfortunes experienced or anticipated; worn with loss of sleep; 
fearful of a generous regime at the table. Here the treatment is 
largely moral, and makes demands upon the tact and courage of the 
physician. Travel, change of climate, variation in the routine of life, 
new social surroundings, are here valuable. The widow must be 
made to lay aside the heavy crape veil beneath which her urticaria 
plays ; the solitary patient must secure a companion capable of 
diverting the nervous attention for a few hours each day. 

It seems probable that to these efficient agencies must be in part 
ascribed the relief so often obtained at the various mineral springs, 
both in this country and abroad. Thus the Karlsbad, Vichy, Sara- 
toga, and White Sulphur Springs, have all been credited with the 
production of beneficial effects in urticaria. 

Prognosis. — The prognosis of an attack of urticaria is, as may be 
seen in what has preceded, exceedingly variable in different cases. 
Simple attacks of the acute sort are trivial, and in a few days the 
patient may retain but the slightest souvenir of the trouble. In the 
case of children, the attack is often at an end in the course of twenty- 
four hours. 

It should, however, never be forgotten that urticaria may torment 
the life of a patient to the utmost bounds of tolerance, and seriously 
impair the general health. Persistent and rebellious chronic urticaria 
may prove to be a more formidable affection than a mild attack of 
syphilis. 

Dermatitis. 

Dermatitis is an affection of the skin characterized by the phenomena of in- 
flammation, including heat, redness, pain, and infiltration, terminating in 
resolution, suppuration, or the occurrence of gangrene. 

Inflammation of the skin occurs in a large number of cutaneous 
affections. Under this title, however, are grouped those inflamma- 
tions where the result is plainly due to a direct influence exerted 
upon the skin by thermal, chemical, or mechanical agencies. These 
inflammations may be mild or severe. 

The milder forms of dermatitis disappear without leaving behind 
them persistent lesions. The graver forms may terminate in gan- 
grene, or produce death by shock or exhaustion. 

Dermatitis, then, is that idiopathic morbid state whose phenomena 
are induced by the action of certain special agencies, such as heat, cold, 
poisons, and traumatism. The inflammatory process may involve the 



172 DISEASES OF THE SKIN. 

superficial <n- deep portion of the integument, or may extend to the 
subcutaneous tissues, or even deeper. The symptoms vary with 
the nature of the cause, the extent and degree of it- influence, and 
the circumstances attending its operation. Hyperemia usually pre- 
cedes and may be followed by a fluid or plastic exudate, by the pro- 
duction of one or more of the several recognized cutaneous lesions, by 
diphtheritic deposits upon the surface, or by gangrene. With these 
there may be general symptoms of mild or severe grade, due to the 
influence excited by the local process upon the general economy. 

[A.] Dermatitis Traumatica. 

External violence, various in character and severity, is capable of 
inducing dermatitis whose symptoms differ in degree, though their 
career is, in general, the same. In this list are included the inflam- 
mation- produced by surgical interference with the continuity of the 
integument; excoriations caused by scratching, by the friction of 
garments and other articles injuriously acting upon the skin; by 
the various implements handled in the trades; and by the bites 
and stings of beasts, insects, reptiles, and fishes, when the result is 
traumatic and not toxic in character. These injuries may be in the 
form of contusion, blow, concussion, pressure, puncture, incision, or 
laceration ; and the consequences are declared in heat, swelling, red- 
ness, and pain ; and in itching, burning, stinging, or pricking sensa- 
tions, with subsequent inflammatory symptoms varying in grade from 
mild and transitory hyperemia and exudation to severe grades of 
inflammation with consequent production of pus, granulation, and 
repair; or gangrene, and separation of the slough; or, finally, by 
repair without consequences. 

[B.] Dermatitis Venenata. 

Certain medicinal and other substances applied to the external 
surface of the skin, are capable of exciting inflammation either by 
operating as caustic, irritant, toxic, or even traumatic agents. In 
this list are included most of the strong acids and alkalies; croton 
oil; cantharides; mustard; tartar emetic; mezereon; the compounds 
of mercury; arnica; turpentine; ether; chloroform; the tarry com- 
pounds ; many of the dyes ; several members of the rhus family (the 
Rhus toxicodendron and Rhus venenata, poison ivy, poison oak); the 
nettle; the smart weed {Polygonum pundatum); cowhage (Muewna 
pruriens) ; and glass in fine powder or delicate filaments, such as are 
thrust into the skin when handling certain articles of Venetian glass- 
ware. The list might be indefinitely extended, as there are few 
articles which are not capable of producing some irritation of the 
surface of the skin, if applied to it with sufficient vigor and for a 
certain period of time; and in some it is difficult to decide whether 
the effect is more traumatic or toxic. An almost equally long list of 
substances of animal origin might be also named having poisonous 
effects upon the integument, such as decomposed or ammoniacal urine. 



DERMATITIS. 173 

feces, ichorous pus, pathologically altered secretions from the uterus, 
eye, ear, nose, etc. 

The symptoms of dermatitis venenata are substantially such as 
have been already described. Numerous types of cutaneous lesions, 
macules, pustules, papules, vesicles, bulhe, wheals, scales, crusts, free 
serous and purulent discharges, subcutaneous abscesses, and even gan- 
grene with sloughing, may result from the operation of such causes, 
the result being largely proportioned to the character of the agent 
producing the injury. 

A few of the more common sources of such accidents may be briefly 
considered. 

The use of soap for laundry, toilet, or other domestic purpoi 
containing an excess of alkali, or even minute particles of bone, is a 
frequent source of trouble, as are also several of the proprietary arti- 
cles sold in the shops for similar employment. In these instances 
the erythema, vesiculation, infiltration, or other symptoms, will 
naturally be distinguished on the hands, or the hands and the face 
Stockings and other undergarments dyed with aniline, picric acid 
chromium, and arsenic, the leather lining of the inside of the hat or 
the cap, and the painted toys to which the lips of children • are ap 
plied, will beget mischief in the various regions of contact for each 
Duhring reports cases where the dye-stuff in the lining of shoes 
penetrated the material of the stockings in women, and produced 
dermatitis of the feet or legs. 

The tincture of arnica, an article unfortunately much used as a 
domestic application for contused and incised wounds of a simple 
character, has produced very serious annoyance in some cases, two 
such having been recently presented at the author's clinic. 

The number of these accidents is annually increasing. Cartier 1 
reports excessive erysipelatous swelling, a phlyctenular eruption, and 
submaxillary adenopathy resulting from the external use of arnica. 
Beauvais reported to the Paris Medical Society gangrenous results in 
one case. Buchner believes this poisonous action to be due to insects 
(particularly the atherix maculatus) found in the calyx of the arnica 
flower. 

Other native plants, a large number of which are enumerated in a 
valuable work by Dr. James C. White, 2 presented before the American 
Dermatological Association in 1886, are similarly effective. Wesener 3 
reports that the Malacca bean tree (Anacardium Orientale) furnishes 
a caustic oil, called cardol, or cordoleum pruriens, which produces, 
after application to the skin, vesicles and vesico-pustules which con- 
tain cardol and terminate by crusting. He reports a generalized 
eruption, beginning on the face, due to this cause. 

The antiseptic dressings of modern surgery are at times responsible 
for eruptive troubles. Among these may be named iodoform, which 
has produced erythema, vesicles, pustules, and wheals. 4 Carbolic 

1 Lyon Med., April 13, 1884. 2 Dermatitis Venenata, Boston, 1887. 

8 Deutsch Arch. f. klin. Med., vol. xxxvi. p. 578. 

4 See paper of Dr. R. W. Taylor, read to the New York Academy of Medicine, 1887. 



174 DISEASES OF THE SKIX. 

acid and corrosive sublimate dressings have had similar effects. 
Many of the articles employed therapeutically by the dermatologist 
should be placed in the same category. Dr. N. E. Green, 1 of London, 
reports severe oedema of the skin followed by desquamation, resulting 
from the application to it of the ointment of ammoniated mercury in 
the strength of two drachms (8.) to the ounce (32.). 

Leszinsky reports a case of dermatitis following the use of a " triple 
extract of heliotrope" as a toilet preparation over the face. 

An exceedingly common source of such dermatitis is urine retained 
upon underclothing in adults. A persistent dermatitis of the scrotum, 
perineum, or inner faces of the thighs in either sex, always calls for 
a careful examination as to whether a few drops of urine are left in 
contact with such underclothing after each act of micturition. 
FistuJse, urinary incontinence, prostatic disease, "stammering of the 
bladder," imperfect finish of the coup de piston in men, especially 
after a gonorrhoea, and similar troubles, are all to be remembered. 

The eruption produced by the poison ivy and other varieties of 
rhus, is almost exclusively an American disease; and from its fre- 
quency in this country has attracted a great deal of attention. A 
certain degree of susceptibility to the poisonous action of the plant is 
requisite for the production of its effects, as some individuals can 
handle the leaves of the plant with impunity, and others are said to 
be affected by its exhalations within a circle having a radius of several 
feet. It is, however, difficult to demonstrate the truth of the last 
statement, suspecting, as one may, that such instances are usually 
cases of contact with other than the suspected plant. The parts 
commonly affected are the hands and the regions to which the latter 
are carried, such as the face, genitals, arms, thighs, and neck. Bare- 
footed children suffer in the feet and legs. Usually the symptoms 
are developed in the course of a few hours, and consist of erythematous 
patches, scanty or profuse vesiculation with abundant, serous weeping 
after rupture of the lesions, swelling, oedema, disfigurement, and 
intense; burning and itching sensations. Serious effects are occasion- 
ally produced. The author has seen deeply attached scars result 
from subcutaneous abscesses of parts greatly swollen. Occasionally, 
in particularly sensitive skins, the eruption spreads from the surface 
affected by the poison, to that where presumably none has been 
applied. It should be remembered, however, that articles of clothing 
may for brief periods of time certainly furnish sources of further 
trouble, being worn at the moment of contact with the plant, then 
laid aside, and, the occasion being forgotten, being subsequently 
employed. Thus a pair of undressed kid gloves after lying for two 
weeks untouched have sufficed to reawaken the disease. 

A number of cases of dermatitis have originated in some parts of 
the Orient from contact with the varnish employed in the finishing of 
lacquered ware. This is manufactured from the rhus varnish A 

1 Brit. Med. Juurn., May 3, 1884. 



DERMATITIS. 175 

few instances of such dermatitis have occurred in this country from 
handling the newly imported articles of this class. 

Careful observation of a typical case, soon after the onset of symp- 
toms, will disclose the exact surface of contact, each being delicately 
outlined by a reddened, tolerably well-defined line, within whose 
limitations will be seen a slightly tumefied, erythematous surface, at 
times displaying closely packed, pin-point sized papules, which may be 
embryonic vesicles, or may proceed to resolution without serous effusion. 

The diagnosis of the eruption will be aided by recalling the features 
described in a careful monograph on the subject by Dr. White, of 
Boston. 1 According to this author, the lateral surfaces of the digits 
first exhibit the symptoms of the eruption ; later, the dorsal sur- 
faces; and latest, the thickened palms. The efflorescence also is 
more irregularly distributed, more uniformly vesicular, and the 
vesicles less transparent than in eczema. These lesions are, more- 
over, more vesicular, and less papular at the onset; and, though 
suggesting papules by their situation in the palm, are in that situation 
readily made to exude serum by puncture with a needle. 

Internal medication is not required. The local treatment is that 
of acute eczema. The application of an alkali for the purpose of 
neutralizing the poisonous volatile alkaloid in the leaves of the plant 
(toxicodendric acid, Maisch) should evidently be considered solely 
with a view to prophylaxis, as it is difficult to understand how such 
neutralization can control the inflammatory process after its onset. 
The black wash, solution of sugar of lead, or oleated lime-water,, 
should be employed at first, and be followed later by the dusting- 
powders. The late Prof. Babcock, of Chicago, a frequent sufferer 
from the disease during his extended botanical excursions, first taught 
the value of an ointment made by incorporating a decoction of the 
inner bark of the American spice-bush {Benzoin odoriferum) with 
cold cream. It certainly has afforded very prompt relief in the cases 
in which one is able to employ it, the difficulty lying in securing the 
bark of the shrub in its young and tender state. 

A long list of topical remedies have been vaunted as specific for the 
relief of this disorder, from the brine of a pork-barrel to a decoction 
of the leaves of the plant itself. As the eruption subsides with satis- 
factory results when protected and not irritated by the local treatment, 
it is not difficult to explain these facts. In this way corrosive subli- 
mate lotions ; the tincture of iron ; bromine, fifteen drops to the ounce 
(32.) of olive oil (Brown) ; dilute nitric acid ; hyposulphite of sodium; 
bicarbonate of sodium ; saturated solutions of chlorate of potassium ; 
and grindelia robusta, a drachm (4.) of the fluid extract to eight 
ounces (250.) of water, have all been found useful. 

[C] Dermatitis Calorica. 

Under this title are included those affections of the skin induced 
by extremes of thermal variation. 

1 New York, D. Appleton & Co., 1878, from the March numher of the New York Medical Journal of 
the same year. 



176 DISEASES OF THE SKIN". 

Unduly high temperatures produce in the skin some redness and a 
slighl degree of swelling, the color not completely disappearing under 

pressure. If the exciting agent be withdrawn before further effects 
arc induced, the color first deepens, then becomes paler, and in twenty- 
four hours the process is usually concluded with a very delicate and 
transitory resulting pigmentation. 

Rays of heat and heated objects at a temperature above 125° to 
175° F. produce immediately, or after a brief interval, first an 
erythema, which disappears when the source of heat is removed; 
second, after more prolonged exposure, the symptoms of active in- 
flammation and exudation. Vesicles or bullae, isolated or confluent 
according to the severity of the cause, may rise from a reddened skin 
which is usually intensely painful. These lesions are persistent or 
transitory, and generally filled with a clear serum, which exudes and 
dries into crusts after rupture of the chamber in which it was im- 
prisoned. At other times the serous exudation is so great that the 
epidermis rises in broad plates, from beneath which the serum is 
exuded. This process may terminate by a free production of pus 
from the surface and gradual resolution. Adenopathy is a frequent 
concomitant symptom. In such dermatitis of extensive areas of the 
skin, the intensity of the process may awaken a violent fever; or 
death may result from shock or exhaustion. 

In yet severer grades there is the production of an eschar, which is 
dry, brown, blackish, and destitute of all signs of vitality ; or, as 
Kaposi describes it, dense, coriaceous, and as white as alabaster, upon 
which, nevertheless, some vesicles may appear, and by their presence 
suggest a false conclusion as to the vitality of the tissues upon which 
they rest. In from eight to ten days the eschar is removed by sup- 
purative processes, and the scene is closed by the usual phenomena of 
granulation and cicatrization. The characteristics of the scar thus 
produced are its great irregularity, its tendency to stellate radiation, 
and the production of ridges, folds, pockets, and bridles. 

Burns involving one-third of the surface of the body are of grave 
portent, and those affecting one-half are generally fatal, even though 
for from twenty-four to forty-eight hours there may be little complaint 
as to pain. The causes of death in these fatal cases are often obscure, 
as the post-mortem results are usually negative. Gastric and duodenal 
ulceration are, however, often recognized. Overheating of the blood, 
heart-paralysis, oligo-cythsemia, and actual destruction of leucocytes 
have all been supposed to be effective. In cases where life is pro- 
longed to the third day, the complications of pysemia, erysipelas, and 
tetanus may arise. Lastly, exhaustion following fever, suppuration, 
haemorrhage, and visceral affections may lead to fatal results. 

In the treatment of the simplest burns, rest, lotions of lead-water, 
and cool water with the application of compresses, are usually suffi- 
cient to secure relief; occasionally the dusting powders may be 
substituted advantageously for these. In the cases where the serum 
is invited rapidly to the surface, with the production of vesicles aud 
bulla?, the latter should be gently punctured to give relief to the 



DEEMATITIS. 177 

4 

tension by the evacuation of their contents, but the roof-wall should 
be preserved, as it may subsequently forfn an attachment to the ex- 
posed derma beneath. The indication then is to exclude the air as 
perfectly as possible and to prevent suppuration, indications admirably 
met by the application of carbolated oil and lime-water with the 
Lister dressing. Continuous immersion in water of the temperature 
most agreeable to the patient, as practised by Hebra in cases of severe 
and extensive burning, produces speedy and certain amelioration of 
the pain, and a favorable condition of the wounds, though it does not 
avert a fatal issue in any dangerous case. 

The strictest antiseptic precautions are demanded when the sup- 
purative process in the skin is both active and extensive. Disin- 
fection with a five per cent, solution of carbolic acid, or a two per 
cent, resorcin solution, should be followed by the application of pro- 
tective silk wet with a five per cent, solution of the sodic biborate, or 
sodic bicarbonate, and the whole enveloped either in borax-lint, 
antiseptic (mercuric iodide) wool, carbolized gauze, or salicylated 
cotton ; over all, the impermeable rubber tissue should be wrapped. 

Nitzsche 1 first disinfects the surface thoroughly with carbolic acid, 
having previously protected the blebs, after which it is covered with a 
thick varnish of linseed oil and litharge mixed by the aid of heat 
with five per cent, of salicylic acid. When this is dry, a second coat 
is applied, and the whole finally covered with a thick layer of wad- 
ding retained in place by an elastic bandage exercising moderate 
compression. Cicatrization is said to progress beneath the dressing 
without changing the latter. When suppuration does occur, the upper 
layer of the wadding is removed, and dried salicylic acid in powder 
is sprinkled over the surface, the wadding being afterward reapplied. 

Skin-grafting may be required to cover the extensive ulcers left by 
the larger burns. 

In Congelatio, or dermatitis from congelation, there are also 
usually, in the milder forms, circumscribed erythematous patches or 
plaques, generally recognized under the name of Pernio, or chilblain, 
seated upon the digits or, more rarely, upon the face, and occasioning 
a disagreeable sensation of heat, smarting, or itching, especially after 
the chilled part has again been warmed. They are bluish or 
purplish-red in color, and often seated on a slightly oedematous integu- 
ment. They are often cool to the touch, when subjectively hot. 
Authors have claimed that anaemia is a chief predisposing cause of 
the complaint, but it frequently occurs in perfectly healthy young 
people. Sir Erasmus Wilson has intimated that some cases of so- 
called lupus erythematosus of the hands belong to this category. 

In the second grade of inflammatory reaction from the state of 
contracted bloodvessels and pallid integument produced immediately 
by the action of cold, bullae and vesicles form, with, in severe cases, 
underlying ulcers. 

In the third grade gangrene may occur, with and without the 

i Deutsch. Med. Zeit., 1881. 
12 



178 DISEASES OF THE SKIN. 

fori nation of bid he. The frozen part may become insensible, white, 
ami cold, without the circulation in it of blood- and lymph-currents. 
From this condition reaction occurs, with the formation of an eschar, 
differing in depth according to the severity of the exposure to cold. 
If, however, over and beyond the interference with the circulation, the 
tissue itself has been destroyed, the part falls at once into gangrene 
when reaction occurs; or bullae form larger than those described above, 
filled with sanguinolent serum; or the skin is smooth, marbled with 
bluish lines, whitish, cold, and insensitive. Mortification ensues, 
followed by the well-known phenomena of the " line of demarcation," 
and, in favorable issues, suppurative separation of the dead part, 
granulation, repair, and cicatrization. As the injuries induced by 
congelation arc more frequent upon the extremities, the bones largely 
participate in the losses of tissue, especially those of the digits. 
Septicaemia and a fatal result may follow. 

Chilblains are treated internally by the ferruginous tonics, particu- 
larly the tincture of iron; externally by stimulant applications, such 
as those containing iodine, camphor, carbolic acid, tincture of benzoin, 
and balsam of Peru. Kaposi recommends : 



R. 



Pulv. camphone 


gr. x; 


Cretae prseparat. 


s.i ; 


01. lini 


fsu; 


Balsam. Peruvian. 


tt\,xx; 



50 



M. 



Frictions, with or without medication, are generally useful. The 
parts are to be carefully protected from pressure and undue friction 
effects. 

Dilute nitric acid and peppermint water in equal proportions, 
painted over the part for three or four successive days, have been 
recommended by Lapatin for the treatment of frost-bitten fingers 
and toes. Hydrochloric and pyroligneous acids, lemon-juice, collo- 
dion, and acetate of lead, both in lotions and poultices, are also 
recommended. Meurisse advises in the management of both severe 
ambustio and congelatio, that goldbeater's skin be applied over any 
salves or lotions employed over the surface. 

In cases of severe congelation the circulation is to be cautiously 
restored by friction in an apartment where the air is cool, in order to 
prevent too energetic reaction. Friction with snow is employed with 
safety in our own country, and in the steppes of Russia where these 
accidents are frequent and grave in consequences. Perseverance for 
hours in this course is often rewarded with success in apparently 
desperate cases. Antiseptic dressings are usually demanded when 
sloughing and ulceration ensue. 

[D.J Dermatitis Medicamentosa. 

The importance of recognizing the fact, that a given eruption is 
produced by an ingested drug, can scarcely be overestimated from 
the point of view of the diagnostician. The errors committed in this 
connection are so frequent and so annoying to the patient that it is 



DERMATITIS. 179 

necessary for the physician to inquire very carefully, before treating 
any cutaneous disease, as to the medicaments previously swallowed 
by the patient ; and also to be prompt to connect any aggravation of 
a cutaneous disease with remedies ordered by himself for internal use. 
The following is but an imperfect list of the drugs whose internal 
administration may be followed by an exanthem ; imperfect, because 
without question many have yet to be recognized as possessing such 
an action. As to the modus operandi of such medicinal agents, for 
the most part our knowledge on this subject is purely conjectural. 
Some, for example, the iodide of potassium, are eliminated in part by 
the glands of the skin, and presumably have thus a local effect upon 
such emunctories ; others, aud in this class, the author believes, 
should be included quinia, induce an urticaria scarcely to be distin- 
guished from an urticaria ab ingestis. Some, possibly, operate in 
either or both ways at different times or in different individuals. 
The absurdity of supposing that any disease can be "driven out" by 
the ingestion of such drugs, should be relegated to the specious ignor- 
ance which first framed such an hypothesis. 

Aconite. — This drug is said to be productive at certain times of 
marked diaphoresis with the occurrence of vesiculation and consider- 
able itching. If so, it is possible that the diaphoresis in an irritable 
skin may be responsible for the trouble. 

Antipyrine. — Ernst 1 has been followed by many observers in 
recording rashes resulting from the administration of antipyrine. 
The symptoms are discrete and confluent patches of bright red, 
scarlatiniform, erythematous, and pruritic macules or papules. 

Arsenic. — Erythematous, vesicular, papular, and much more 
rarely pustular, bullous, and ulcerative lesions, occur upon the face, 
back, and hands, after the ingestion of arsenic. The well-known 
effects of the administration of the drug in toxic doses, upon the 
mucous membranes of the eyes, nose, and mouth, need not be 
described in this connection ; nor yet the grave, gangrenous symp- 
toms, with osseous necrosis, which have been observed in the workers 
with the metal. 

The author has seen a bright red, scarlatiniform blush with few 
isolated vesicles cover both shoulders of a young woman with a 
delicate skin after taking three medicinal doses of Fowler's solution, 
the eruption being present, but less distinct upon the face and hands. 
In two cases the rash in polymorphic type was limited to the hands 
alone. 

A number of young patients have been sent to the author's clinic 
from that for nervous diseases, who having taken arsenic in the 
largest medicinal doses for relief of chorea, presented as a result, a 
dark discoloration of the skin of the chest andneck chiefly, but also 

i Ctlblt.f. Klin. Med., 1885. 



180 DISEASES OF THE SKIN. 

of other parts of the body. This was suggestive of the bronzing 
seen in Addison's disease. In some instances there had been no 
other cutaneous symptoms. Guaita and Liege have noted these phe- 
nomena, usually in the tilth month after ingestion of the drug. 

By far the largesl number of such rashes are, however, produced 
in those previously suffering from cutaneous disease, for whose relief 
the drug is administered. Here the toxic effect is declared either by 
— first, increased hyperemia of the skin visible in an erythematous 
patch, or beneath the scales of a squamous patch; or, as an areola 
of bright red hue about any aggregations of lesions; second, by 
simple aggravation of the type of a disease already in existence 
(recurrence of acuity in a subacute eczema) ; third, by rapid peripheral 
extension of a disease which had previously been well limited in 
contour ; fourth, by converting a disease exhibiting uniformity of 
lesion into one characterized by multiformity. Each of these results 
might be illustrated by cases. 

In a series of eight cases of poisonous effects produced by arsenical 
paper hangings, and reported by Dr. F. H. Brown, 1 there were, 
curiously, no cutaneous symptoms. 

Belladonna, Atropia. — The well-known erythematous, scarlat- 
iniform, or reddish efflorescence produced by belladonna and its 
alkaloids, is usually limited to the upper segment of the body, but 
may become generalized. It is said to occur more frequently in 
children, probably because it has been administered largely to indi- 
viduals of that age under the superstition that it was useful as a 
prophylactic in scarlatina. Very disagreeable and even dangerous 
results have followed the instillation into the eye of atropia as a 
mydriatic, the rash being accompanied by constitutional symptoms. 

Boric Acid. — Modadewkow reports a case in which the pleura 
was washed out with a five per cent, solution of boric acid, a part 
of which was not removed. There occurred as a result an erythe- 
matous rash over the face, trunk, and extremities. 

Bromine and its Compounds. — A full and valuable account of 
the cutaneous effects of this drug and its compounds, when adminis- 
tered internally, is contained in a paper on medicinal eruptions, read 
by Dr. Arthur Van Harlingen, of Philadelphia, before the American 
Dermatological Association in 1880. Acneiform lesions, pustules, 
macules, maculo-papules, papules, eczema-form moist patches, fur- 
uncles, urticarial wheals, scales, aud ulcers have been induced by 
swallowing the bromides of potassium, sodium, ammonium, and 
lithium. By far the most common are the acneiform and pustular 
lesions, occasionally accompanied by pruritus, which appear upon the 
face and upper portion of the trunk, though the author has seen the 
rash very distinct upon the genital region. Duhring reports an 

1 Paper read before the Boston Society for Medical Observation, March 6, 1876. 



DERMATITIS. 181 

interesting observation of a case in which the eruption simulated very 
closely the maculo-papular syphiloderm, the patient having taken 
the remedy for three years. The eruption first appeared within five 
or six days after decreasing the dose. Kaposi has observed a case in 
a nine-months-old suckling, the mother having taken one hundred 
and twenty grammes of the bromide of potassium in two months, 
herself not exhibiting traces of eruption. In one patient treated by 
myself the eruption was generalized, but in no part exaggerated. It 
occurred in an adult male after three months' continual employment 
of large doses of the same salt. 

Mr. Browse, of Cambridge, England, recommends for relief of 
these symptoms the application of a solution of salicylic acid, one 
grain to the ounce (0.066-32.) of water, frequently applied on lint, 
having successfully treated in this way sores as large as the palm of 
the hand. 

T. C. Fox and Gibbes report condyloma-form lesions in the case 
of an infant where the histology of the lesions was carefully studied ; 
and Fay, in a child eleven months old, also recognized lesions which 
had been mistaken for molluscum epitheliale. These were un- 
doubtedly similar to the 'condyloma-form rash seen in children after 
the administration of the iodide of potassium. 

Cannabis Indica. — The only instance thus far reported of an 
eruption produced by the ingestion of this drug was observed by 
myself in the case of an adult male, who was extensively covered 
with papulo- vesicular lesions after swallowing a grain (0.066) of the 
extract. 1 

Chloral. — An erythematous rash is the most common of the 
eruptions produced by chloral, though wheals, red and yellowish 
papules, vesicles, pustules, and petechial blotches have been observed. 
It occurs upon the face, neck, trunk, and limbs, of the latter especially 
on the extensor surfaces. In a man of advanced years, totally deaf, 
who had slept only under the influence of chloral for four years, the 
author observed discrete scaly patches as large as saucers over the 
lower extremities, hands, and feet. 

Martinet 2 reports an erythematous and scarlatiniform rash, occa- 
sionally commingled with urticarial and purpuric lesions, occurring 
upon the face, neck, front of the chest, the extensor surfaces of the 
larger joints, and the dorsum of the hands and feet. There was no 
pyrexia nor indisposition, but in cases dyspnoea and cardiac palpita- 
tion. 

Cod-liver Oil. — According to Farquharson, 3 cod-liver oil after 
being swallowed is capable of producing an acne. This can be true 
only of very inferior specimens, such as are not rarely found in the 
English market. 

i N. T. Med. Kecord, May 11, 1878. 2 These de Paris, 1879. 

3 Brit. Med. Journ., Feb. 22, 1879. 



182 DISEASES OF THE SKIN. 

Copaiba and Cubebs. — The Ingestion of copaiba is occasionally 
followed by a vividly red rash, in the form of discrete macules, more 
rarely maculo-papules, invading chiefly the lower segments of the 
extremities and the skin of the belly, but often completely covering 
the surface. The author has seen the rash occur in dark mul- 
berry-red petechias ; and always in his experience accompanied by 
pruritus. Inasmuch as the drug is often administered for the relief 
of a venereal disorder not syphilitic, care should always be taken not 
to confound the eruption it may excite with the early macular syphi- 
loderm. Cubebs is much more rarely followed by a similar result. 

CUNDURANGO. — (Timtz 1 reports the occurrence of furuncular and 
acueiform lesions in twenty patients out of one thousand who were 
taking cundurango for the relief of syphilis. 

Digitalis. — In Behrend's treatise on diseases of the skin 2 refer- 
ence is made to cases where macular and maculo-papular rashes 
succeeded the ingestion of digitalis. 

Iodine and its Compounds. — The iodide of potassium is respon- 
sible for the larger number of all eruptions in this category. The 
frequent employment of this drug and the very marked influence 
which it possesses over the skin, render the study of these morbid 
results important. 

Unlike many of the other substances in the list, the iodine com- 
pounds are followed by some species of rash in probably the larger 
number of all persons who swallow them. 

The resulting lesions may be macular, papular, vesicular, bullous, 
pustular, petechial, multiform, or in the form of circumscribed, sub- 
cutaneous abscesses. 

The macular rash is best seen fully developed over the upper 
extremities, in discrete erythematous patches or in a diffuse blush. 
The cases in which the author has studied it, all displayed sym- 
metry. The hands were chiefly affected, and suggested in appear- 
ance the dyed hands of the aniline worker. It is said to assume at 
times the papular type, a transformation the author has not noticed, 
though he has seen coexistence of papules upon the face. 

Berenguier describes a scarlatiniform rash of sudden occurrence 
upon the surface of which were numerous minute discrete vesicles. 
Eczema-form eruptions with abundant serous exudations are also 
reported. 

A number of interesting cases are on record where the adminis- 
tration of the drug was followed by the production of bulla?. Bum- 
stead, Taylor, Duhring, Tilbury Fox, and Finny, have described 
such in adults, and the author has seen several cases in children. 3 
Hallopeau 4 also reports a case in which a bullous eruption followed 

i Vierteljahrscht. f. Dorm, u Syph , 1882. - Braunschweig, 1879. 

» Arch, of Derm., Oct 1870. Journ. of Cutan. and Ven. Dis., 188G, p. 383. 
•> Union Med., March 25, 1882. 



DERMATITIS. 183 

the ingestion of the iodide of potassium. The patient died, and the 
post-mortem appearances are reported in full. The eruption occurred 
chiefly about the head, neck, and the upper extremities. The author 
has called attention to the significant rarity of vesicular and bullous 
lesions in acquired syphilis, and suggested that at least some of the 
cases on record were those of rashes induced by the remedy given 
for relief of the disease. 

A careful analysis of these bullous rashes leads to their division 
into three categories : first, those occurring often with fatal results in 
cachectic adult patients; second, those occurring as part of the erup- 
tive lesions in a polymorphic group ; third, those occurring in well 
nourished children, taking on the appearance of molluscum epitheliale 
and condyloma lesions, usually compounded of papulo-vesicles and 
pustules. Erythanthemata of a similar type have been also recognized 
in infants after the ingestion of bromide of potassium. 

The pustules induced by the administration of iodine compounds 
are seen chiefly upon the face, neck, trunk, and arms. They are 
usually seated upon a firm base, and may be followed by cicatrices. 
Duhring has seen an annular patch upon the forehead, made up of 
minute vesico-pustules, which eventually developed into a globular 
violaceous mass, nearly two inches in diameter. On several occasions 
the author has observed large cherry-sized, tubercular elevations 
abruptly rising from the surface of the integument, and presenting 
a cribriform appearance, which showed the open ducts of several sup- 
purating follicles (chin, cheek, nose). 

The purpuric rash occurs in petechial macules, discrete and miliary, 
situated chiefly on the lower extremities. In a case reported by Dr. 
Mackenzie (quoted by Van Harlingen) a single dose of two and a 
half grains (0.166) in an infant, was followed by a fatal result after 
the petechias appeared. 

Jaborandi and Pilocarpine are capable, when ingested, of 
inducing free diaphoresis, and erythematous macules, wheals, and pin- 
head sized papules have been seen upon the surface as a result. 

Mercury. — The statement that mercury when ingested is capable 
of producing an erythematous rash upon the surface of the skiu, is 
made by several authors of reputation. In view of the fact that the 
metal has been, in its various compounds, administered for so long a 
period of time, and for so many various diseases without the produc- 
tion of cutaneous symptoms, it is a fair hypothesis that the few 
reported cases are those in which there was coincidence rather than 
causation. The author has had the opportunity of observing a large 
number of individuals in whom the drug had been both properly and 
very injudiciously employed for long periods of time, and has not 
been able in a single instance to discover any evidences upon which to 
base a belief in its power to produce a cutaneous exanthem. A 
similar statement was made by Dr. White, of Boston, when this 
subject was under discussion in the American Dermatological Associa- 



184 DISEASES OF THE SKIN. 

tion. Mercurials, when applied to the external surface of the body 
are, as is well known, capable of exciting, in various degrees, cuta- 
neous irritation and inflammation. 

Opium am> era Alkaloids. — Erythema, wheals, and occasion- 
ally intense pruritus, with oedema, and subsequent desquamation, 

have followed the ingestion of opium and several of its alkaloids, 
notably morphia. In its mildest expression this cutaneous effect is 
limited to a characteristic itching about the nostrils, which can be 
perceived in a large proportion of all patients as soon as the general 
effect of the opiate becomes apparent. In several cases the author has 
observed an intense and distressing general pruritus without efflor- 
escence; and in some instances has been certain that the subsequent 
urticarial efflorescence was induced by the free diaphoresis which the 
medicament induced. This is a matter of some practical moment, 
as the use of an anodyne for the purpose of procuring sleep for a 
patient tormented with a nocturnal pruritus, would seem to be 
occasionally indicated. Inasmuch as chloral, the bromide of potas- 
sium, and the opiates are all capable of aggravating such distress, 
great caution is in such emergencies needful. In general, it may 
be said that the employment of these and similar remedies for such 
a purpose, should be interpreted as a confession of weakness on the 
part of the physician, who ought to be able to alleviate the distress 
of his patient by a judicious employment of topical remedies. 

Phosphorus. — Hasse (quoted by Van Harlingen) cites the case 
of a youug girl who exhibited a pemphigoid rash after the ingestion 
of phosphoric acid ; and, according to Farquharson, 1 phosphorus 
itself is occasionally responsible for purpura with gastro-intestinal 
derangement and jaundice preceding a fatal issue. 

Podophyllin. — Winterburn 2 reports that those who work in 
resinoid podophyllin, are liable to suffer, as a consequence of this 
exposure, from a cutaneous disease of the scrotum. 

Quinine, Cinchona, and its Alkaloids. — Morrow 3 has col- 
lected in an interesting' paper, the record of over sixty eases of 
quinine exanthem, and shows that its prevailing type is exanthe- 
matous, the rash being of a bright vivid hue, disappearing on 
pressure, and resembling scarlatina. Other lesions produced are 
wheals, papules, vesicles, petechia*, hemorrhagic purpura, bulla?, and, 
in one instance, an intense localized dermatitis with commencing 
gangrene of the scrotum. In some cases the rash reappeared on 
repetition of the dose,' and even after recourse to the other alkaloids. 
The subjects were mostly women. As with most of the other exan- 
them-producing drugs, small doses, where the idiosyncrasy existed, 
sufficed for the effect. The author has seen the rash in an adult male, 

i Loc. cit - Louisville Med. News, April 21, 1882. 

•■'■ N. Y. Med. Jouru.. March, 1880, p. 244. 



DERMATITIS. 185 

who, after taking two grains (0.133), of the sulphate of quinia 
for the first time in six years, exhibited an efflorescence over the 
entire surface of the body, of discrete, finger-nail sized, salmon- and 
pinkish-tinted, scarcely elevated patches, accompanied by a moderate 
pruritus. A repetition of the dose was followed by a recurrence of 
the exanthem. 

In several cases desquamation is reported as resulting from the 
rash. As to the occurrence of the general symptoms recognized 
under the title of cinchonism (tinnitus aurinm, etc.), these may and 
may not accompany the lesions. Morrow makes the pertinent sug- 
gestion, in view of the frequent similarity of the rash to that 
exhibited in scarlatina, that many cases hitherto recorded as recur- 
rent attacks of that disease and measles, with other anomalous cuta- 
neous eruptions, may have been instances of the quinine exanthem. 

Salicylic Acid and the Salicylates. — Reports of cases 
where these substances after ingestion have produced cutaneous 
symptoms, have been made by Heinlein, Wheeler, and Freudenberg, 
all cited by Van Harlingen. The symptoms were diffused redness, 
urticarial lesions, vesicles, pustules, petechia?, and vibices, accom- 
panied by intense pruritus, and followed by desquamation. 

Santonine. — A generalized eruption of urticarial lesions seated 
upon a reddened surface, and accompanied by oedema, is reported by 
Sieveking as occurring in a child to whom santonine had been admin- 
istered as a vermifuge. 1 

Sodium Benzoate — Rohe 2 reports two cases in which an erythem- 
atous rash, with well-defined border, accompanied by itching and 
slight desquamation, occurred during the use of the benzoate of 
sodium. The patients were a woman, aged thirty-five, and a boy 
with diphtheria. The eruption disappeared on the discontinuance of 
the remedy, and was made successively to appear and disappear by 
its alternate use and disuse. 

Sodium Biborate. — Gowers 3 reports the occurrence, especially on 
the arms, but also over the trunk and legs, of an eruption resembling 
psoriasis, after the ingestion of the biborate of sodium. Some of the 
resulting patches were one inch and a half in diameter. Three cases 
in all are collated. In two the eruption faded when a solution of 
arsenic was added to the sodium salt. 

Stramonium. — Deschamps (cited by Duhring) reports an erythem- 
atous rash after the administration of the thorn-apple. 

Strychnia. — Skinner (cited by Van Harlingen) reports a case 
where an eruption of six weeks' duration ensued upon the adminis- 

1 British Medical Journal, February 18, 1871. 

2 Maryland Medical Journal, June 15, 1881, p. 91. 

3 Lancet, September 24, 1881. 



186 DISEASES OF THE SKIN. 

tration of quinine and strychnia together; the former in the dose of 
one and a half grains (0.10), the latter in the dose of one-twenty- 
fourth of a grain (0.0025). 

Tanacetum. — A varioliform eruption produced by the ingestion 
of a drachm and a hall* (6.) of the oil of tansy, administered for 
abortifacient purposes, is reported by Porter. 1 There were antecedent 
clonic convulsions. The result was not fatal. 

Tab and Turpentine. — Erythematous, vesicular, and papular 
rashes arc reported as resulting from the ingestion of these substances. 

The diagnosis of the various medicinal rashes described above does 
not, fortunately, demand a recognition of the essential peculiarities 
impressed upon each by the exciting cause, since in many cases such 
peculiarities do not exist. The urticaria? resulting from the ingestion 
of "head-cheese," quinine, and chloral, may be absolutely indistin- 
guishable. But to establish the fact that a medicamentous eruption 
is present in any given case, is a long step in the direction of reaching 
the precise cause that has been in that case effective. This fact 
must often be obtained from the lips of the patient. The medicinal 
rashes are in general remarkable for their sudden appearance, their 
symmetry, their diffusion over large areas of the integument, the 
presence of pruritus, the absence of fever, and their existence alike 
upon exposed and protected surfaces of the skin, hinting thus at the 
action of some cause not operating externally. Excluding syphilis 
and the exanthematous fevers, a generalized rash of sudden occurrence 
should always raise the suspicion of a dermatitis medicamentosa. 
Similarly in cases of preexisting cutaneous disease, syphilis, eczema, 
or psoriasis, the sudden occurrence of lesions of a new type widely 
diffused, or of rapid aggravation in situ, or of speedy extension as to 
area of those already in existence, should awaken the suspicion, if 
there be fever, of the exanthemata ; and, without a febrile process, of 
the medicinal rashes. Thus the author has seen two patients with 
eczema exhibit rapid rise in temperature, and subsequently develop a 
generalized variolous rash ; and it is a matter of common experience 
to examine patients on the eve of a macular syphiloderm, or even long 
past the eruptive stage of that disease, showing their faces, necks, and 
shoulders covered with an acneiform rash produced by the potassium 
iodide. The practitioner cannot be too strongly urged to view with 
exceeding watchfulness the skin of any patient affected with either of 
the common disorders, eczema, acne, and psoriasis, when the eruption 
in any instance becomes anomalous as to type, distribution, or symp- 
toms. An illustrative example has come under my observation since 
the first paragraph of this chapter was written. A physician, on a trip 
from Colorado to Chicago, with a long standing eczema of the scrotum 
aud thigh, suddenly exhibited tumefaction of both hands with small 

1 New England Medical Journal, October 15, 1881. 



DERMATITIS. 187 

egg-sized, discrete, dull red plaques over the palms and dorsa ; and in 
the centre of nearly all such lesions a firm, whitish, elevated wheal 
accompanied by severe burning, tingling, and pricking sensations. 
He had been swallowing "bromidia," a proprietary preparation con- 
taining the bromide of potassium, the hydrate of chloral, and cannabis 
indica, each single drug being capable of inducing an exanthem, and 
yet he had not the slightest suspicion of the real nature of his symp- 
toms, having been questioned by a brother physician, to whom he 
exhibited his hands, as to the possibility of syphilis. 

The medicamentous rashes, as a rule, disappear rapidly after the 
withdrawal of the exciting cause, and require no further manage- 
ment. In some cases the soothing lotions, baths, and dusting powders 
employed in the treatment of acute eczema may be required. 

It should not be forgotten that the patient who exhibits these 
lesions is usually one who has been suffering from the real or fancied 
disease for relief of which the drug was taken, and that condition 
may require recognition and management. 

In Morrow's contribution to this subject, it is clearly shown that 
the same drug may produce a variety of eruptive phenomena, and 
that the same eruptive features may result from the ingestion of 
different drugs. He points to what he concludes to be the neurotic 
origin of many of these rashes, and believes that the proof is incon- 
clusive that these are, to any considerable degree, brought about by 
elimination through the cutaneous glands, of the noxious element 
introduced with the drug. Tilden, 1 however, calls attention to the 
fact that many of these eruptive phenomena are of the nature of 
angioneuroses, similar to Trousseau's " tache cerebrate," requiring 
often increase in the irritability of the cutaneous vessels, with exuda- 
tion of serum, outwandering of cells, aud, in case of heemorrhagic 
lesions, some change in the vascular walls themselves. 

[E.] Dermatitis Gangrenosa. 

Idiopathic and symptomatic cases of dermatitis terminating in 
gangrene, where no history of external violence or caustic application 
has been obtained, are reported by several authors. In most of these, 
single or multiple, circumscribed, erythematous or hemorrhagic 
macules have been followed by superficial gangrene with sloughing, 
the process being in some instances attended with constitutional 
symptoms of such gravity as to result fatally. In certain other cases 
the affected patches presented at an early period the mummified and 
alabaster white aspect, noted at times in dermatitis calorica. In 
establishing a diagnosis in such cases, care should be taken to exclude 
the forms of senile gangrene occurring in the lower extremities as 
the result of vascular calcification, when the skin and deeper tissues 
are alike invaded ; as also the cases of simulated eruption produced 
by caustics upon the skin with a view to deception. In the latter 

1 Pathogenesis of Certain Affections of the Skin, June 9, 1885. 



188 DISEASES OF THE SKIN. 

class, a distinguishing feature of the lesions is their occurrence chiefly 
upon those part- of the body most accessible to the hands: and, in 
persons not ambidextrous, upon those parts which the hand pre- 
dominantly employed can most readily reach. 

Ca>c~ of "symmetrical dry gangrene of the fingers and to 
multiple ulceration terminating in gangrene, "asphyxia of the 
extremities," and others described under similar titles, are annually 
recorded. Some of them appear to have a neurotic or angio-neurotic 
origin : some are peripheral symptoms of diseases of internal organs 
or of the vessels ; some are cases of locomotor ataxia, the shrivelled 
or gangrenous spots on. the hands and feet being merely early symp- 
toms of the perverted nutrition due to the spinal sclerosis. Atkin- 
son's case, 1 and that of Eichoff and C. Boeck, assigned by this author 
to the group of affections termed by Simon " multiple cachectic gan- 
grene," seem to belong to this same category which includes the 
" symmetrical gangrene" of Raynaud, or, as it is often termed, 
''Raynaud's disease." Mr. Hutchinson has reported instances 
where the tendency to this disorder appeared to be transmitted 
through three generations, the lesions not progressing in some indi- 
viduals of the group beyond the "asphyxiated" condition to that of 
gangrene. Terrillon 2 reports perforations of the hand as preceding 
symptoms of a disease of the central nervous system supposed to be 
locomotor ataxia, which resemble the similar lesions of the feet 
reported by Atkin 3 in a case of undoubted ataxia. 

Petit and Verneuil 4 have referred these disorders to a malarial 
origin. 

Drs. Flynn and Clark, of New York, 5 have also reported sym- 
metrical gangrene of the extremities in men of advanced years. 

In many of these cases the preliminary stages of the process 
either did not exist, or were too transitory for observation. The 
first appreciable external symptoms were the perforating ulcer, the 
shrivelling phalanx, the gangrenous patch, or the completely "asphyx- 
iated " tissue. For the relations of these to a large group of tropho- 
neurotic affections of the skin, the reader is referred to the chapter 
devoted to the neuroses. 



Erysipelas. 

Gr. ipvdpog, red ; irkKha, the skin. 

Erysipelas is an acute and specific inflammation of the skin and subcutaneous 
tissue, characterized by diffuse, shining redness, pain, swelling, and elevated 
temperature of the affected part, terminating in desquamation, and usually 
accompanied by fever. 

Symptoms. — The disease is usually preceded by a prodromic period 
of malaise, lasting for twenty-four hour- or less, which may be 

1 Multiple Cutaneous ("lceration. Amer. Journ. of the Med. Sci., 18S4. 

2 Rev. Medic*!, Jim.- !:'.. 1>S".. :i Brit. Med. Journ., Julv 24, 1886, 
* i;.v. d.- Chtfurg., Nob. 1, 3, 6, and 9, 1883. 6 \. y. Med. Record, 1886. 



ERYSIPELAS. 189 

ushered in by one or several chills followed by febrile symptoms. 
The latter are accompanied by anorexia and often by vomiting with 
general depression and headache. 

The eruptive symptoms are generally first displayed at a given 
point, from which the disease progresses. It is commonly first 
noticed in a nut- or egg-sized patch, the integument of which is 
tumid, slightly elevated, irregular in contour, distinctly circumscribed, 
and presents a rosy or crimson-reddish color with a peculiarly smooth 
and characteristic shining or glazed appearance. The sensations 
awakened may be those of moderate pruritus, pain, heat, or burning. 
To the touch, the affected part is tender, moderately firm, and per- 
ceptibly hotter than normal. The color fades under pressure to a 
yellowish- white. 

In typical cases, the erysipelatous blush and swelling spread over 
an area which may be of the size of the palm, or may even cover the 
surface of an entire limb or region of the body. In cases of moderate 
grade, the inflammation attains a maximum of extent and severity 
within a week, remains apparently unaltered for a day or more, 
and then begins to abate, with amelioration of all the concomitant 
symptoms. The fever which often precedes the eruption, continues 
unabated during its progress, the temperature rising to 105° or 106° 
F., with nocturnal exacerbation, cephalic and lumbar pain, dryness 
of the tongue, gastric distress, and occasional delirium. As invo- 
lution of the disorder is accomplished, the redness is replaced by the 
brownish, bluish-red, and dirty-white shades often seen after the 
disappearance of erythema multiforme, the epidermis finally desquam- 
ating in various degrees according to the extent of the preceding 
inflammation. 

In other cases, where the exudation of serum beneath the epidermis 
has been rapid, the latter is raised iu the form of vesicles, pustules, 
or bullae, more often the latter ; and, precisely as in the severe forms 
of dermatitis calorica, with which erysipelas presents a certain 
analogy, gangrene of the skin may result in the part affected. This 
is particularly apt to follow the disorder when it attacks the seat of 
surgical wounds and injuries. 

Erysipelas Ambulajsts is a term used to describe that form of 
the affection in which the erysipelatous blush, after involving a given 
area, spreads with greater or less rapidity to the parts in the vicinage, 
either by direct extension and uniform advancement in one direction, 
of the tumid and distinctly circumscribed border ; or by linear, 
digital, or irregular prolongations radiating from the inflammatory 
focus. As the blush and swelling advance in one direction, there is 
usually correspondingly rapid disappearance on the other. At other 
times, the disease, while extending to a new area and abandoning the 
old, is relighted in the latter, and thus an irregularly involved and 
irregularly extending erysipelatous surface presents for weeks the 
varying phenomena of the disease. In yet other cases again, chiefly 
those in which there has been a history of traumatism, a long 
erysipelatous linear streak or band may spread from the site of the 



190 DISEASES OF THE SKIN. 

traumatism in one direction or another, suggesting the indurated 
lines observed in lymphangitis. In severe eases, the febrile, nervous, 
and other symptoms are grave, including coma, delirium, meningitis, 
and the signs of serious involvement of the lungs, pericardium, 
pleura, and bowels. Metastatic abscesses may also occur in the 
cutaneous and subcutaneous tissues, the joints, peritoneal cavity, and 
even in the viscera. Death may result from these complications, or 
from shock, exhaustion, or pyaemia. 

Surgical accidents aside, the face is the most common seat of the 
disease, where it may be first seen upon one side of the nose, one 
cheek, the lips, or the eyelid. It often attacks the lobe of the ear 
after the operation of piercing the lobule for the insertion of ear-rings 
in women. Thence it may extend over the whole face, inclusive of 
the mucous linings of the mouth and nose, which present a dry, 
tumid, and glazed appearance, suggestive of the symptoms displayed 
upon the skin. 

The inflammation may extend to the hairy parts, but in many cases 
it exhibits a species of reluctance to transgress the limits there pre- 
sented. It may be noticed in cases of mild grade where no applications 
have been made to arrest a local progress, that the elevated border 
spreads symmetrically to within a few lines of the male beard or 
the hairs at the edge of the forehead, and there spontaneously rests. 
In severer grades these limits are readily surpassed; and then, as a 
rule, the extension is rapid and formidable. In this way the entire 
head may become enormously swollen, suggesting to a casual observer 
that it is fully twice its normal size. The patient may then be greatly 
disfigured; his scarlet lips, swollen, parted, and permitting the escape 
of saliva; the ears, as usual when greatly enlarged, projecting in a 
marked degree from the side of the head ; the lids cedematous and 
incapable of separation ; the face, disfigured by bulla? or crusts; and 
the mind disordered by violence of the fever or the accesses of 
delirium. When recovery ensues, the hairs are apt to fall. 

All other regions of the body may be invaded, as the vaccinated 
arm, the leg whose skin is involved in venous varicosities, the 
scrotum or umbilicus of the infant, the genitalia of the newly deliv- 
ered woman, the breast of the nursing mother, and every surface 
which has been the seat of punctured, incised, contused, or poisoned 
wounds, or other accidents of the integument. 

Several authors describe habitually recurrent and Chronic forms 
of ERYSIPELAS, whose identity with the disease here described, it is 
difficult to establish. The diagnostician is sufficiently often consulted 
in cases where an erythematous eczema of the face, an acne rosacea, or 
asymptomatic erythema, is described by a patient as chronic or recur- 
rent "erysipelas." The lesions to which such terms, however, are 
restricted by careful writers, are often forms of chronic dermatitis, 
such, for example, as occasionally follow dermatitis calorica. In- 
stances occur in which the face, or parts of it, are the seat of a low 
grade of inflammation with local heat, swelling, redness, consid- 



ERYSIPELAS. 191 

erable infiltration, and some tenderness, the part being irritable and 
worse after exposure to a high wind or after excesses at the table. 
But the most of such cases fail to exhibit the distinct imprint of 
erysipelas ; they are not only chronic in course, but exceedingly indo- 
lent, lasting for years ; they are unaccompanied by fever; they are 
distinctly limited in all accesses of aggravation to the same part of 
the face ; they are never characterized by a bullous efflorescence ; they 
never completely disappear ; many occurr in the subjects of chronic 
alcoholism. 

The febrile symptoms are, throughout, persistent and characteristic 
of a specific toxaemia. The temperature, as has been seen, may reach 
105°-107° F., with vespertine exacerbations and remissions; it may 
also become subnormal. If not relieved in the course of seven or 
eight days, complications may be expected. These are oedema, 
abscess, phlegmonous inflammation, gangrene, and inflammatory acci- 
dents involving the membranes of the brain, lungs, heart, bowels,, 
kidneys, peritoneum, and joints. 

Etiology. — The modern view of the invariable origin of erysipelas 
from some point, however insignificant as to size, where a morbid 
germ has secured access to the economy, is generally accepted and 
adds interest to the study of the local manifestation of the disease. 
Whether it be the slightest or severest traumatism, an erosion, a torn 
pustule, or a puncture by a pin, such lesions are now interrogated 
whenever erysipelas occurs in any part of the body or in the course 
of auy other disease. 

In the face, catarrhal and ulcerative processes involving the mucous 
membrane of the mouth, ears, and nose, are often the cause of an 
erysipelas, these processes occurring in a wide range of disorders 
from syphilis of the nasal bones to caries of the teeth. Injuries of, 
and surgical operations upon the scalp not conducted with antiseptic 
precautions, and the common piercing of the lobe of the ear in 
women and female children for the insertion of ear-rings, may be 
followed by the appearance of the disease upon the scalp, as a' result 
of which the hair often falls. Fistulse, vaccination, lesions of the 
tender umbilicus of the newly born infant, and railroad accidents 
may be named as common causes of the disease in other regions. 

Predisposing causes of this disease are to be sought for in cachexia, 
epidemic influences, traumatism, violation of hygienic rules, and occa- 
sionally, the recurrence of previous attacks. Besides these, it is 
alleged that constitutional predisposition and particular articles of 
diet may be responsible for the disease (mussels). 

If the disease be invariably the result of infection due to the 
presence of a micrococcus, the essential cause lies in the specific 
germ, in the absence of which none of the predisposing causes named 
can be effective. It is clear, however, that the predisposing causes 
suggested are those in which the multiplication of such germs and 
their entrance to the general economy are most facilitated. 

The infectious nature of erysipelas has been demonstrated by clin- 
ical proof, and the experiments of many, observers, including H liter, 



192 DISEASES OF THE SKIN. 

Nepveu, Wahlberg, Lukomsky, Koch, Orth, Fehleisen, 1 and others. 
The micrococci recognized by them were seen in great abundance, 
often arranged in chains, in the curium, subcutaneous tissue, and 
lymph spaces of erysipelatous skin, never in the bloodvessels. 

Other views as to the etiology of the disease have been advanced. 
Hebra and Kaposi believed it to be due to the secondary products 
of local inflammation ; others have held to a "malarial" origin 
(Cohnheim). Among later observers, Tillmans concludes that the 
infection of the disease may be transmitted by fluids both containing 
micrococci and without them. 

The conclusion is irresistible that the disease is always the result 
of the admission of specific bacteria to the human body by the avenue 
of a lesion of the surface, however insignificant in size. 

Women are rather more subject to the disease than men. The 
disorder is also apt to occur in spring and autumn. 

Pathology. — Under the microscope, the skin and subcutaneous 
tissues are seen to be infiltrated, the exudate being more serous and 
less rich iu protoplasm than that observed in ordinary phlegmonous 
inflammation of the skin. The bulla? represent rapid exudation of 
this same serosity to the congested epidermis, aud the elevation of 
the latter in consequence. The elements of the rete and connective 
tissue are for the same reason swollen, the lymphatic and bloodvessels 
enlarged, and the cutaneous follicles engorged, the root-sheaths of the 
hairs being occasionally separated, necessitating thus the temporary 
loss of the pilary growth. In proportion to the severity of the 
exudative process, pus corpuscles may appear and represent, for the 
most part, degenerative changes iu the subcutaueous tissues resulting 
in abscess. The phenomena are, in short, those of superficial or 
deep-spreading dermatitis. After death, the skin which has been 
the seat of the disease cannot be distinguished microscopically from 
that of another body. 

Diagnosis. — Erysipelas is to be distinguished from the ervthemata, 
from dermatitis of various grades, from eczema, and from scarlatina. 
As a rule, its recognition from all is readily effected, when the 
presence of the fever in erysipelas is had in view, as also the peculiar 
shining, swolleu, and rosy-reddish to damask hue of the affected 
parts. The redness is never produced as in scarlatina by multiplicity 
of reddish puncta, nor is it so widely diffused as in that disease. 
Erysipelas may be at times accompanied by a pruritic sensation, but 
the patch which it affects is never by any possibility scratched. By 
this simple test alone one may often distinguish an erysipelas of the 
face from an eczema of the same region in a child. From a chronic 
dermatitis with thickening of the affected tissues and redness of the 
surface, erysipelas is to be distinguished by its tendency to spread, by 
its acute career, by its frequent association with bullous or vesicular 
lesions, and by the color, outline, and raised border of the affected 
patch.- However, it must be understood that to these localized 
patches of chronic dermatitis several authors have given the name, 

1 Die Aetiologiu iles Erysipelas. Berlin, 1883. 



ERYSIPELAS. 193 

chronic erysipelas, the difference between the views held on this point 
being chiefly one of terms. 

Treatment. — Upon the continent of Europe, the therapeutic man- 
agement of erysipelas is in general limited to the employment of such 
systemic and topical measures as are specially required in each case. 
Quinine is administered whenever indicated by the temperature 
record ; and the erysipelatous surface is either left exposed to the 
air, covered by dry compresses, moistened by eold or hot aqueous 
lotions, or anointed with unguents, simple, mercurial, or anodyne, as 
suggested in each case. Occasionally cataplasms are applied over the 
inflamed surface. Abscesses, whether subcutaneous or connected with 
a carious tooth, are opened ; the contents of all pustules evacuated ; 
and crusts carefully removed. Kaposi lays stress upon freeing the 
nasal cavities of all inflammatory products, whenever the face is 
attacked. 

The method of treating erysipelas by the administration of the 
tincture of iron internally has long been popularized among American 
practitioners. This preparation is given in full doses, from twenty 
to fifty drops, day and night every two to three hours, irrespective 
of the febrile state. When the erysipelatous blush has a distinctly 
circumscribed outline, the annular zone extending for an inch or 
more in width upon the sound and affected skin is either covered 
with the tincture of iodine, pencilled with a crayon of nitrate of 
silver, or painted with a saturated solution of the same salt. This 
is done with a view to limit the extension of the disease. It is true 
that these measures will not always succeed, but it is erroneous to 
assert with some authors that they always fail. Certain it is that, 
whether effective or not in the production of the result, the advancing 
border of the disease will often fail to surpass the limits thus artifi- 
cially described. Collodion has been employed for a similar purpose, 
and lately Darlin 1 has written in advocacy of the revival of this 
method of treating the disorder, basing its claim on the fact that it 
diminishes the temperature of the part thus protected, and that, by 
the compression excited, it interferes with septic absorption. Heppel 2 
recommends the painting over the surface of a ten per cent, solution 
of carbolic acid in alcohol, as an abortive treatment, for which 
Braithwaite 3 substitutes a similar solution of tannin. 

Excellent results are occasionally reached in the local treatment of 
erysipelas, first by attempting to limit the extension of the disease by 
the application of the tincture of iodine over the peripheral zone ; 
and, secondly, by retaining over the entire surface affected, neatly 
applied compresses saturated with a solution of the hyposulphite of n 
sodium in the strength of about one drachm (4.) to the ounce (32.). 
Dr. Spencer, of the United States Army, has frequently seen the 
disorder upon the face entirely relieved in this way in forty-eight 
hours. 

1 Bull. Gen. de Ther., 1881, vol. ii. p. 239. 

2 Arch, of Derm., April, 1881. 

3 Brit. Med. Journ., April, 1881. 

13 



19-i DISEASES OF THE SKIN. 

With many judicious practitioners all attempts to limit the exten- 
sion of the disease by local applications of an irritating sort(corrosive 
sublimate, nitrate of silver, carbolic acid, tar, turpentine, etc.) are 
condemned as positively injurious. Dry heat is applied by the aid of 

cotton or wool ; or cold compresses are laid over the part; or iced 
lead lotions with intermissions of application ; or salicylic acid, 
boric acid, iodol, or iodoform, in powder, llesorcin in solution has 
been followed in some eases by excellent results. 

Erysipelas rarely attacks a patient in vigorous health. The 
large majority of all the subjects of the disease are either those who 
have previously suffered from manifest general ill-health, or who 
have been complaining of local ailments, trifling wounds, nasal 
catarrh, or surgical accidents. It is these precedent conditions which 
often demand the special attention of the physician or surgeon. 

It is needless to add that all surgical indications are to be fully 
met when these are present : pus is to be evacuated, crusts removed, 
and drainage secured. The physician and surgeon alike should never 
forget that the disease is infectious, that the patient is to be isolated, 
and to be supplied with an abundance of pure air; and that fomites, 
surgical instruments, and even the uon-disinfected hands of the 
attendants are capable of transmitting the disease. 

Finally, there are forms of erysipelas which are remediless. 
These are usually septic in character. The scarlet blush spreading 
from an irreparable injury of long duration, is often the last protest 
of nature against the damage which even her final resort of gangrene 
will not avail to repair. 

Prognosis. — Under favorable circumstances, erysipelas, even of 
severe grade aud extensive invasion, terminates in complete resolu- 
tion. Reserve should be made, however, in every case, as a serious 
complication has often transformed the simplest into the gravest 
forms of the disease. The author has seen an erysipelas of mild grade 
originating in the irritation of the lobe of the ear by an ear ring, trans- 
mitted to a child who died with gangrene of the entire mucous lining 
of the oral cavity. The very young, the cachectic, the victims of 
drink, the aged, the inmates of hospital wards depressed by other 
illness, aud those mentally distressed by destitution and neglect, are 
particularly liable to suffer from grave and fatal forms of the malady. 

The patients who fill the beds in most lying-in hospitals are young 
women, either unmarried or deserted by their husbands, and unpro- 
vided with the necessities of life by those upon whom such a respon- 
sibility rests. The mental depression thus originating in connection 
with the septicemic influences too common in all large charities, is 
responsible for much of the relation which erysipelas often seems to 
sustain to the puerperal state, as also for the appalling mortality 
which it may exhibit under these circumstances. 



FURUNCULUS. 195 



Furunculus. 

Lat. furunculus, a petty knave. 

Furunculosis is a disease characterized by the occurrence of one or more 
circumscribed, cutaneous or subcutaneous abscesses called furuncles, which 
usually terminate by necrosis of tissue in the centre of the phlegmon, its 
expulsion in the form of pus or a core, and a resulting cicatrix. 

Symptoms. — Furuncles, or Boils, commonly begin as both tender 
and painful indurations in the skin or its subjacent tissues, the sum- 
mit of which soon becomes visible in the epidermis as a reddish 
punctum. It is the result of an active inflammatory process, limited 
to a definite area, and of greatest intensity at the centre of the in- 
volved mass. This centre is often represented by a hair-follicle, the 
pustule that forms subsequently being perforated by a hair. 

More or less rapidly thereafter these symptoms are succeeded by 
increased redness, heat, and tumefaction, the latter producing a nut- 
or egg-sized tuberosity, well projected from the surface, or fairly 
imbedded within or beneath the derma. A yellowish point in the 
centre of the erythematous swelling soon announces the occurrence 
of suppuration. When accidentally or artificially opened at this 
summit, exit is given to a thick yellowish pus which may be com- 
miugled with blood from the traumatism of the neighboring capil- 
laries. The small abscess may then, after discharging its purulent 
contents for a few days, gradually close by granulation, or may also 
expel from its cavity a tenacious, pus-covered, yellowish-green 
slough, known as the " core." This evacuation is usually followed 
by relief of the tense and throbbing pain which is the well-known 
subjective characteristic of the furuncle. 

The length of time requisite for the completion of this process 
varies, with the exteut of tissue involved, from a few days to several 
weeks. Boils may occur in any part of the body, but are most 
common about the face, the auricular region, the neck, the armpits, 
the ano-genital region, the hips, the buttocks, the breast, and the 
extremities. They may occur as single or multiple lesions, or may 
succeed each other in crops, especially about the buttocks, trunk, and 
thighs, for a period of several mouths. It is this succession of boils 
to which the term furunculosis is specially applied. The disease of 
the skin, in such cases, may produce a constitutional effect manifested 
in pyrexia. This is usually encountered when the furuncles are few 
and short-lived, only in individuals of irritable constitutions. There 
is also a decided chloro-ansemia due to the pain, fever, purulent drain, 
derangement of the nervous centres, inappetence, and consequent 
perversion of nutrition. 

The sequelae of boils are maculations of a violaceous tint, often 
perceptible in the skin for weeks and even months after their disap- 
pearance ; and cicatrices, pin-head to coin-sized, which are permanent. 

Etiology. — The causes of furunculosis, as also of a single furuncle, 



196 DISEASES OF THE SKIN. 

are often exceedingly obscure; and it must be admitted that the sub- 
ject requires more extended study. It is true that both conditions 
are encountered in typical subjects of " hospitalism," where anaemia, 
asthenia, marasmus, malnutrition, and exhaustion resulting from 
excesses, from grave general disease, from low fevers, and from ner- 
vous strain, play a prominent part. But the reverse is also true. The 
author has recently, for example, had under his care a gentleman of 
superb physique, active habits of life, and large -wealth, who availed 
himself of all the resources of medical skill, and who had yet suffered 
for six months from a persistent furunculosis. Few actively engaged 
practitioners have foiled to see similar eases. 

On the other hand, scratching, eczema, scabies and. other cutaneous 
diseases, lice, and external irritants of various sorts are responsible 
for nmny boils, especially those that are few and not followed by 
similar lesions. When, however, such sequence occurs, it should 
never be forgotten that the furuncles, if sufficiently numerous and 
large, are amply capable of disturbing the general economy. The 
collar-button at the back of the neck; the edges of an unyielding 
corset, for one unaccustomed to it ; a hard bench; the saddle-tree; 
and many similar articles, may be the exciting cause of furuncles. 

Account should always be had, in cases of persistent furunculosis, 
of externally operating poisons. In this category must be included 
sewer-gas emanations, arsenical wall-papers, and the poisons handled 
in the trades, e. r/., by dyers, lead-manufacturers, etc. 

Lastly, it is exceedingly common for patients thus affected to apply 
to practitioners for remedies intended to " purify the blood ;" and, 
inasmuch as the iodide of potassium is often mischievously prescribed 
in response to this demand, the original trouble is thus enhanced to 
a manifold extent. Many cases of furunculosis are instances of boils 
resulting originally from external irritation, which have greatly mul- 
tiplied and finally profoundly affected the system under the impulse 
of the so-called "blood-purifying" process. 

Patholoyy, — Authors have attempted to explain the phenomena of 
furuncle by supposing the process to be due to inflammation attack- 
ing a sebaceous follicle in the derma ; or a pilary follicle or sweat- 
gland beneath the skin ; or the peri-follicular tissues ; or the con- 
nective tissue pedicle which passes downward from the fundus of the 
hair-follicle to the subcutaneous tissue ; or the blood and lymphatic 
vessels which surround the sac. It is reasonable to suppose that 
they are all in the right. No one of these component parts of the 
skin is known to be exempt from the changes which are induced by 
the inflammatory process. It is difficult to discover in the furuncular 
lesion any symptoms which set it apart from the other results of 
localized inflammation, its phenomena differing from those of 
ecthyma, acne, pustular eczema, anthrax, etc., only by the seat and 
extent of the inflammation. The core of the furuncle represents a 
necrosis induced by the violence of the exudation, and so does the 
gangrenous slough which falls after a severe dermatitis calorica. The 
core of the furuncle is moist, yellowish, and puriform, because it is 



FURUNCULUS. 197 

completely immeshed beueath the epidermis, and pus-soaked. The 
core or slough of a gangrenous dermatitis may be as dry as a crust, 
from desiccation in consequence of exposure to the air, or be in 
various degrees moistened by the fluids escaping from the tissues 
beneath. Where there is no core in furuuculus, this absence is prob- 
ably due to the fact that the purulent products of the inflammation 
pass with readiness from the peripheral to the central parts of the 
phlegmon without having to leak through or between, or to be 
pressed against, masses of centrally disposed elements, whose vitality 
is thus the more readily lost. Inflammation of tissue in a practically 
closed chamber, under tense pressure, under slight pressure, exposed 
freely to the air, or in all grades protected from it, will always differ 
in its phenomena. It is wiser to attribute these diifereuces to the 
circumstances under which it is displayed than to any peculiarities in 
the nature of the process itself. 

The contagious character and parasitic origin of furuncles have 
been studied by a number of observers. Giugeot, 1 Startin, Trastour, 
Lowenberg, Pick, Pasteur, and others have, with varying success, 
reproduced these lesions by experimental inoculation. The name 
torula pyogenica has been given to a vegetable parasite recognized in 
furuncular products, which, however, in development, is to a marked 
degree modified by the nature of the site in which it is implanted. 

It is with these demonstrations in view that Gingeot suggests the 
employment of parasiticides in the treatment of furunculosis, the 
acid nitrate of mercury, iodine in tincture, carbolic acid, and borated 
alcohol. Internally sulphur and the hyposulphite of sodium in large 
dilution are administered. 

Diagnosis. — Boils are to be distinguished from carbuncles by the 
exaggerated symptoms of the latter, described below. Circumscribed 
furuncular abscesses of the groins and axilla? are not to be con- 
founded with suppurating, sympathetic, or virulent buboes of these 
regions, associated with genital or extra-genital, contagious, venereal 
sores. This goes without saying ; but many such errors have been 
made. Furuncles of the anal and genital region may be significant 
of surgical affections of the neighboring parts (perineal, peri-prostatic, 
peri-urethral, and scrotal abscesses in men ; suppuration of the 
vulvo-vaginal gland in women, etc.). 

Treatment. — The debilitated constitution of many patients affected 
with boils indicates clearly the need of a tonic regimen, including the 
administration of iron, quinine, and strychnine, the mineral acids, 
and, contrary to the generally accepted opinion of the laity, a gene- 
rous diet of milk, cream, eggs, and fresh meats. To these, wines 
and malt liquors may be at times added with advantage. Change of 
climate, of diet, of cooks, and of the habits of life is most service- 
able in cases of prolonged furunculosis. The mineral waters, at some 
of our health resorts, prove especially valuable for the debility which 
often results from these disorders. The internal remedies which 

i Bulletin gen de Therap., Jan., Feb., and Mar. 1885. 



198 DISEASES OF THE SKIN. 

possess reputation in this complaint are arsenic, sulphur, and the 
sodic sulphites, the alkalies, tar, phosphorus, and the sulphide of 
calcium. 

The last-named is probably more highly esteemed by the larger 
number of practitioners than all other internal remedies, and is 
given in doses of one-fifth to one-tenth of a grain (0.0133-0.0066) 
every three or four hours in the day. In lithsemia, the aeetate or 
citrate of potassium is given in large dilution ; in gouty states, col- 
chicum and the alkalies, including the sodie salicylate. No one of 
these articles, however, may be deseribed as an efficient and certain 
remedy tor the complaint; many eases will progress without hin- 
drance from any or all of them. 

Attempts in the direction of aborting a furuncle may occasionally 
l»e made by the topical application of the stronger alkalies (aqua 
ammonia') or acids; caustics or cautery ; ice, or premature complete 
incision with the scalpel. These measures will occasionally succeed ; 
more often they fail. Frequent renewal of hot poultices of powdered 
slippery elm or flaxseed, to which an opiate may be added for the 
relief of the acute pain, should be practised till suppuration is estab- 
lished, and exit given to the pus or core. For a brief time after- 
ward, they may lie continued. Subsequently the treatment is by 
carbolated lotions and simple ointments. 

Prognosis. — The future of the patient affected with a prolonged 
furunculosis is that only of which there can be question. Eventually 
the worst cases are relieved when unaccompanied by systemic or 
visceral disorders, and where the circumstances of the sufferer permit 
him to pursue the most advantageous course (travel, diet, abstraction 
from business, etc.). The resulting cicatrices depend upon the 
severity of the process. Often they are small, and in the course of 
years scarcely distinguishable. In exceptional cases they are large, 
persistent, and disfiguring. 

Anthrax. 

Gr. avdpa^, a live. coal. 

Anthrax is a circumscribed, cutaneous and subcutaneous abscess, usually 
larger than a furuncle, characterized by dense induration and sloughing, 
and terminating, in favorable cases, by the production of a persistent 
cicatrix. 

The term anthrax is employed by several foreign authors to desig- 
nate the disease known among the English as murrain, splenic fever, 
or malignant pustule, the charbon of the French. It is here 
employed solely in the description of the non-specific carbuncle. 
The malignant carbuncles clue to the presence of bacteria will be 
described under the title, Malignant Pustule. 

Symptoms. — Carbuncles are often preceded by malaise, chill, and 
pyrexia of severe grades. In cases where the anthrax is formidable 
and seated upon or near the head, alarming symptoms of prostration, 
stupor, somnolence, and even coma, may be noted. With and with- 



ANTHRAX. 199 

out these concomitants, a dense, dull-red, indurated, and painful 
phlegmon soon appears, varying in size from a small hen's egg to an 
orange and even much larger, involving not only the skin, but the 
tissues beneath. Suppuration finally occurs ; but the pus is not con- 
fined to a single sac. It undermines the integument, and often, 
through several apertures, leaks out indolently to the free surface. 
The fenestrated or cribriform appearance of the skin covering the 
carbuncle constitutes, in this stage, one of its most striking features. 
Through these apertures may be distinguished the whitish or yel- 
lowish pus-soaked sloughs, or portions of a single slough, which can 
be at times extracted through the orifice. Often the entire mass separ- 
ates in a single slough, involving the skin and subcutaneous tissues, 
leaving a crateriform ulcer of formidable size, which, in favorable 
cases, proceeds to heal by granulation. The resulting cicatrix is at 
first of a deep violaceous tint, and later becomes blanched. It is 
indelible. 

The fever which usually accompanies this process may be mild or 
severe, or, more commonly in dangerous cases, of a typhoid character. 
It results unquestionably from sepsis due to unli berated pus and 
necrotic tissue, and is naturally most grave in consequences where 
the patients are weakened by previous asthenic disorders. Under 
these unfavorable circumstances, the carbuncle may spread at the 
periphery, with islands of necrotic tissue and ill-conditioned pus ( 
separated by bridges of empurpled, infiltrated, and yielding skin. 

The peculiar lesions of this disease most often appear upon the 
back of the neck, the back of the trunk, and the lateral aspect of 
the hips and thighs, usually in single development, though occasion- 
ally two or even three carbuncles of small or medium size may co- 
exist. The reason for their appearance in the localities named is 
clear. It is here that the skin is most thick and resisting, and, as a 
consequence, purulent foci when formed are covered in by the most 
voluminous layers of the connective tissue of the corium. 

Etiology. — Anthrax is produced by the obscure causes to which 
reference has already been made as probably effective in the produc- 
tion of boils. The two may coexist; or the one follow the other; and 
intermediate forms occur which might be assigned to either class. 
The disease is encountered more often in men than in women, and in 
later than in earlier life, simply because the tissues constituting its 
sites of preference offer in these individuals, and at these ages, a 
greater resistance to the exit of pus. The bacilli which may be recog- 
nized in many cases may sustain an etiological or purely accidental 
relation to the lesion. 

Pathology. — The pathological anatomy of carbuncle is well 
described by Warren, 1 whose observations conclusively show that 
the inflammatory process here is one with that seen in the simplest 
pustule. The peculiar symptoms of carbuncle are due solely to the 
formation of the phlegmon beneath the dense and extremely thick 
masses of fibrous tissue found in the back " for the protection of 

1 The Tathology of Carbuncle, or Anthrax, Cambridge, 1881, p. 15. 



200 DISK A S ES F T HE S K I X . 

that comparatively defenceless portion of the body." The elements, 
multiplying with the intensity of the inflammatory process, first in 
the subcutaneous adipose tissue, pass upward along the fat columns 
described by Warren as columnse adiposae, crowd these, push along 
their horizontal clefts branching from either side, infiltrating the 
derma, pass along the edges of the hair-follicles, till the papilla? till 
the latter ''balloon" with pus, ooze to the surface through the cribri- 
form apertures in the undermined epidermis, and soak the bundles 
of fibrous tissue, relatively intact, which constitute the undetached 
mass of sloughing tissue. 

It cannot lie doubted that the general symptoms in anthrax, 
pyemic, septicemic, sympathetic, are due solely to pus imprisonment. 

Frr,. 34. 




Vertical section of anthrax. Dense network of fibrous bundles, with interspaces communicating and 
extending to the subcutaneous tissue. (After Warrex ) 

Fig. 35. 




Section of anthrax. Infiltrated papilla? are seen at I, distended in balloon-shaped figures, between 
which the rete is compressed ; at p and mp columnae adiposae are seen ; /, division of elements, the 
fibrous bundles resolving into protoplasm. (After Warrex.) 

Diagnosis. — It follows from what has preceded that carbuncle and 
furuncle differ solely in consequence of the depth of the starting- 
point of the phlegmon, and the density and resisting power of over- 
lying tissue. The former is therefore flatter, denser, less rapidly de- 
veloped, larger, less tender, and more painful, opens by many rather 
than by one or two apertures, and is followed by larger sloughs, 
ulcers, and cicatrices, and occasionally by fatal results. 



ANTHRAX. 201 

Treatment. — Crucial and other deep incisions in the local treat- 
ment of carbuncle are certainly inferior in results to the method 
advocated by Wood 1 and Talor, 2 which are employed in cases with 
complete success. A saturated solution of pure carbolic acid is 
injected through the several apertures in every direction into the 
sloughing tissues by the aid of an hypodermatic syringe. When the 
orifices are not sufficiently numerous, the point of the needle is thrust 
through the thinned integument at the summit of the swelling in 
several points. The pain is severe, but short-lived ; the tissues are 
blanched, indurated, and destroyed ; the slough in a few days is 
readily separated after division of its slender fibrous attachments; 
and the ulcer rapidly contracts with the sequel of a smaller scar. 
It is necessary to use pure acid in saturated solution to prevent 
absorption of the injected fluid and resulting toxic effects. 

Relief is afforded in many cases by opiated hot cataplasms and 
fomentations, with the requisite skill in the surgical dressing of the 
parts by carbolated lotions, extraction of the slough wholly or in 
portions by the forceps, and the subsequent employment of simple 
or carbolated unguents during the reparative process. An excellent 
method of withdrawing the purulent and sloughing contents of the 
carbuncle is to apply over it, at the proper period, an exhausted 
receiver, such as a common cupping-glass. 

In many cases the antiseptic treatment of a carbuncle furnishes 
decidedly the best results as regards the comfort of the patient and 
limitation of the disease. Here there is absolutely no surgical inter- 
ference with the lesion, beyond the incisions made for the evacuation 
of pus. The violent squeezing and manipulation of the carbuncle 
are interdicted. It is freely powdered with iodoform, and on it is laid 
soft, felt cloth, thickly spread with any emollient and antiseptic salve. 
Bulkley 3 advises the use of the ordinary zinc salve for this purpose. 
Boric acid in powder, or iodol, thickly dusted over the carbuncle and 
covered with antiseptic wool will also be found a useful dressing. 

Iuternally calx sulphurata should be administered in full doses. 
It has an unquestionable effect in diminishing the pus-formation. 

Other constitutional treatment is that demanded in the case of 
furunculosis, including the liberal employment of tonics, a generous 
diet, a strict observance of the rules of hygiene, and stimulants 
when indicated. Pyrexic, septicemic, pysemic, and adynamic states 
require the special management of such complications, including cold 
sponging of the surface in fever, and the use of quinine and stimu- 
lants, with artificially applied heat in the algid condition. 

Prognosis. — A serious issue need be anticipated only when the 
complications described above are grave in character, or occur in 
asthenic constitutions. 

Pustules from Cadaveric Infection. — The lesions generally 
known as dissection-wounds usually occur upon the hands of those 

1 Toledo Medical and Surgical Journal, Dec. 1880. 

- Austral. Medical Gazette, Dec. 1, 1881. 

8 Journ. of the Amer. Med. Assoc, May 16, 1885. 



202 DISEASES OF THE SKIN. 

exposed td the danger of post-mortem examinations and dissections. 
At the point of inoculation, which may be either the site of a 
former abrasion, rent, or the month of an open follicle, a painful 
vesico-pustule, papule, tubercle, wart, furuncle, or hemorrhagic bulla 
rises rapidly from an angry and indurated base, with hypersemic 
areola in dull red shades. Suppuration, crusting, or ulceration may 
follow, limited to the seat of the lesion ; or lymphangitis in various 
grades with consequent pysemic or septicemic involvement of the 
system. Suppurative and non-suppurative axillary buboes are 
common. Gangrene and necrosis of the soft parts and bones, especi- 
ally the phalanges, may ensue, as also a fatal result from the systemic 
disorders named. In a few cases a chronic marasmus is induced. 
Prophylaxis, by proper protection of the hands and the immediate 
cleansing and disinfection of any accidentally wounded point, is of 
the highest importance. The treatment is to be conducted in accord- 
ance with the principles already described. 

There is reason to believe that accidents of this kind may be pro- 
duced by absorption of the alkaloids engendered in the cadaver by the 
decomposition of proteid substances, called ptomaines. These were 
first isolated and named by the late Professor Selmi, of Bologna, 
subsequent investigation seeming to prove that in chemical constitu- 
tion they do not differ from the alkaloids produced by albuminous 
decomposition in vegetables. Brieger has identified neuridine, cada- 
verine, putrescene, and saprine in the dead body, and, with these a 
peculiarly toxic alkaloid to which he has given the name mydalein. 
All these are capable, after ingestion or admission by other avenues 
to the circulation, of inducing salivation, vomiting, diarrhoea, dysp- 
noea, paralysis, and death. The lethal issue in the case of lesions of 
the character here designated, is probably due to the fact that, at the 
site of the pustule of irritation or traumatism, one or more of these 
toxic alkaloids has gained admission to the lymphatic circulation. 
For further reference to this subject, the reader may consult the 
chapter on Verruca Necrogenica. 

Pustules and Other Lesions resulting from Wounds In- 
flicted by Reptiles and Insects are often of an insignificant 
character. Such are the trivial results of the bites and stings of 
flies, fleas, mosquitoes, ants, bees, hornets, etc. At other times, 
however, serious and even fatal consequences have been recorded. 
The wounds produced by the tarantula and scorpion (which frequently 
lurk in the clusters of tropical fruits now imported to almost every 
part of this country), as also of the venomous reptiles, may prove to 
be grave. Urticarial, vesicular, pustular, papular, bullous, and 
petechial lesions may thus originate and be the cause of a more or 
less severe dermatitis with toxic symptoms. In the latter event, it is 
common in this country to administer as remedial agents, alcoholic 
stimulants as freely as they can be ingested. 

Delhi Boil, Aleppo Evil, and Biskra Bouton. — These are 
chronic endemic disorders characterized, for the most part, by the 



ANTHRAX. 203 

occurrence of painful nodosities upon the face, hands, and other 
portions of the body. The lesions are often multiple papules, which 
subsequently become purulent and ulcerate indolently ; or become 
covered with scales. They are often grouped iu patches and followed 
by cicatrices. The exact nature of the maladies thus named, is 
unknown. They are quite fully described by Fox, Farquhar, 
Pollack, Willemin, and other authors, as occurring in India, the 
region about the Euphrates and Tigris Rivers, and along the northern 
coast of Africa, especially Algeria and Morocco. The descriptions 
given of these diseases certainly suggest that, in some instances at 
least, several different disorders have been included under these titles, 
such as the lesions of lupus, syphilis, and the frequently formidable 
symptoms produced in the skin by the vegetable parasites in tropical 
countries. The author has personally journeyed from Arabia in the 
East, along the coast to six degrees below the line in South Africa, 
and thus enjoyed a fair opportunity of observing the symptoms of 
many of the endemic disorders of that region. In no single instance 
has the author been able to persuade himself that the numerous 
furuncular, papular, and pustular affections encountered, differed 
from the similar lesions observed in temperate climates, except in 
that they were greatly aggravated by filth, meagre diet, intense heat of 
climate, ignorant and vicious medication, and the syphilitic diathesis. 
Laveran 1 has lately described afresh the Biskra bouton. It occurs 
not only in Biskra, but also in the adjoining oasis, and is plainly 
identical with the Aleppo boil. It shows itself as an endemic only 
in the months of September and October, and continues till Decem- 
ber. No new cases appear in January and February. All ages, 
both sexes, the strong and weak, are liable to it. The eruption 
affects the face and extremities by preference, sometimes also the 
trunk. It ordinarily attacks the same person but once, yet may 
recur. So long as the disease prevails, the least excoriation has a 
tendency to become Biskra button. At first there is a reddish, pain- 
less elevation of the skin, the size of a pin's head ; the centre of this 
soon dries, and a brownish crust forms, easily removable. Beneath 
this, there is a small round ulcer. The papules may occur in patches, 
bearing thick crusts which long resist. The crusts are remarkably 
dry. When the latter are removed and the ulcer left undressed, a 
new, less firm crust forms ; when dressed, the crust- formation is pre- 
vented and an ulcer of an obstinate character remains, which in the leg 
is not unlike a varicose ulcer. If the original crusts be not disturbed, 
these eventually fall and leave no scar. Should, on the contrary, 
the crust be removed at the beginning of cicatrization, this is accom- 
plished slowly, and a permanent scar remains. Lymphangitis, 
erysipelas, and phlebitis, occur as complications. There are no 
peculiarities in the crusts. Epidermic cells, pus corpuscles, and 
bacteria, are commonly recognized by the microscope. An expectant 
treatment is the best. Should the crusts be removed or fall off, it is 
advisable to powder the ulcer with henna, which favors the procluc- 

1 Aimal. de Derm, et de Syph., 1881, t. i. p. 173. 



204: DISEASES OF THE SKIN. 

tion of fresh crusts and cicatrization. As regards its pathogenesis, 
the author holds Weber's view, that the disease is contagious and 
inoculable, and perhaps auto-inoculable. The virus exists in the 
crusts, but its nature is not established. Carter's opinion as to its 
parasitic nature is uot tenable. 

Dr. Altounyan, of Turkey, 1 protests against the view, given above, 
entertained by Geber and others that the Aleppo button is a term 
applied indefinitely to various cutaneous disorders. In his view it 
is a specific disease beginning, independently of the hair-follicles, as 
a small acne-form papule, disappearing on pressure and pinkish in 
color. Afterward it grows deeper, larger, and harder, and becomes 
more adherent and more vascular. Still it is livid, sensitive, smooth, 
and boggy to the touch. Pus forms centrally and dries into grayish- 
brown crusts which are rupioid in character. Beneath is a spongy 
ulcer, with ragged margin, ovoid contour, and ichorous discharge. 
Healing is by the production of a permanent and deforming scar, the 
entire course of the disease lasting one year. 

Dr. G. R. Eliott, of New York, who made a microscopical exami- 
nation of some specimens furnished him by Altouuyau, reports that 
the disease was limited to the epidermis and corium, and its area 
occupied by small round inflammatory or formative cells and 
epithelial elements. There was a distinct line of separation between 
the healthy and diseased tissue. No cryptogams or other micro- 
organisms were recognized. The hair-follicles and other glandular 
structures were intact. 

Altouuyau found the best treatment to be the painting of the 
button with the tincture of iodine ; and that one attack furnished 
immunity against a second. He believes the disease to result from 
the bite or stinsr of an insect. 



Phlegmona Diffusa. 

Gr. fyleyfxovf], an inflamed tumor. 
Phlegmona Diffusa is a grave form of non-circumscribed inflammation of the 
skin, in which the integument becomes livid, hot, swollen, painful, and apt 
for necrosis, this process occurring in one or many places to a considerable 
depth, and accompanied by fever and systemic disturbance. 

The word phlegmon is employed by most English and American 
writers to indicate a circumscribed inflammation of the skin, ter- 
minating naturally in suppuration, and, as to the tissues involved, 
larger than an ecthymatous pustule, and yet not large enough to be 
termed an abscess. Circumscribed phlegmons are represented by 
most furuncles, and, at one stage certainly of their career, also by 
carbuncles. 

In the disorder, however, under consideration, the symptoms, both 
local and general, are far more serious. The first evidence of trouble 
may be a severe chill, followed by high fever and deep-seated ham- 

1 Journ. of Cutan. and Ven. Dig., viii , No. 6. June, 1885. 



PUSTULA MALIGNA. 205 

mering pain, felt in the part which is the seat of the disease. This 
is soon recognized as an oedematous area, of dull red or livid hue, 
tensely infiltrated, of the familiar brawny type and indeterminate 
outline. All of these symptoms rapidly increase as resolution is very 
rarely attained, and are followed by suppuration at one or more 
points. In diffuse phlegmon, however, the brawny tenseness of the 
inflamed skin has been so great that vascular thrombosis occurs, and 
the circulation is greatly impeded, as a consequence, between the 
points where pus forms, or about a single point. The tissues then 
become more or less necrotic, both during and after the formation 
and evacuation of pus. 

The fever meantime may abate or entirely remit, or, in grave 
cases, steadily persist. In the latter event, the subcutaneous tissue, 
fascia, periosteum, bones, joints, and ligaments may be involved. 
But in all favorable cases the systemic condition is greatly improved 
when pus is no longer deeply or extensively formed, and when the 
gangrenous shreds and sloughs are well loosened or entirely removed. 

The "Acute Purulent (Edema " of English authors and the Gan- 
grene Foudroyante of the French may be regarded as severe types of 
diffuse phlegmon. In most of such cases the patients die septicemic 
before the complete evolution of the cutaneous inflammation has been 
reached. In others, the affected part, suddenly losing its tense 
brawny hardness, becomes emphysematous, or crepitates with bubbles 
of gas produced by decomposition. The patient may then become 
somnolent or delirious, or be the victim of an intercurrent and fatal 
involvement of the kidneys, lungs, liver, spleen, or bowels. 

The treatment of diffuse phlegmon is largely surgical, and in this 
day simple. Incision, drainage, and disinfection are the three essen- 
tial requirements. These thoroughly assured, the systemic treatment 
is by quinine, stimulants when indicated, and the accepted remedies 
for the typhoid condition generally, including rest in the recumbent 
posture and a proper supply of wholesome air and food. Amputation 
of limbs may be necessitated in order to save life. 

The prognosis rests almost entirely upon the extent, diffusion, and 
severity of the local inflammation, and the systemic condition of the 
patient. In a previously healthy subject, with good hygienic environ- 
ment and the absence of thrombosis, pyaemia, septicaemia, and ery- 
sipelas, the results will generally be favorable. With the reverse of 
these conditions, the outcome may be serious as regards the loss of a 
limb, deformity, or a. fatal issue. 

Pustula Maligna. 

Malignant pustule is a grave carbuncular lesion occurring usually upon 
exposed portions of the body, which may result in gangrene, accompanied 
by a specific fever, and usually resulting from inoculation with a virus 
obtained from some of the lower animals. 

This disease in man is fortunately rare of occurrence, and is usually 
derived from some animal affected with the specific malady variously 



206 DISEASES OF THE SKIN. 

termed "Anthrax," " Charbori," "Splenic Fever," "Splenic Apo- 
plexy." or "Texan Fever." The lesion under consideration is also 
termed Splenic Fever Carbuncle. After inoculation with the disease 
from any infected animal, the human subject may (a) perish from 
systemic poisoning- wholly septicemic in character with few external 
symptoms; or, (/>) when life is sufficiently prolonged, suffer from 
visceral symptoms, and exhibit subcutaneous tumors; or (c) exhibit 
the symptoms of the disease now under consideration. 

In from twelve to eighteen hours after inoculation, a painless 
macule is first manifested, usually upon the dorsum or other parts 
of the hands or face to which the virus has had access. This is 
followed by an inflammatory and pruritic papule, which is rapidly 
transformed into a flaccid vesicle filled with a bloody serum and 
surmounting a firm indurated "nucleus," or a larger blood-filled 
bleb reposing upon a somewhat painful, engorged, and ofteu densely 
indurated base. Oue or more similar lesions may follow in the sur- 
rounding integument, coalescence of which produces a large, angry, 
(edematous, and ofteu gangrenous ulcer. The involved skin may be 
as large as. a small coin, or of the size of the palm of the hand. 
The lymphatic vessels and ganglia enlarge, and often suppurate ; 
metastatic- abscesses form; and the constitutional symptoms super- 
vening are those described in connection with equinia. 

If recovery ensues, the grangrenous mass is sloughed off as iu 
favorable eases of carbuncle ; if the result is to be fatal, the process 
is rapidly aggravated by ^edematous infiltration extending to a wider 
area and by larger quantities of tissue falling into necrosis. 

In some cases the accompanying fever is high, with marked 
delirium ; in others, it is of a typhoid character. Death results from 
shock, septicemia, or exhaustion, though in cases where the lesion is 
circumscribed and unattended by constitutional symptoms, recovery 
may ensue. 1 

Etiology. — The disease is commonly induced by infection from 
one of the lower animals, usually horned cattle, who suffer from 
charbon or splenic fever, and are in relation to herders, ranchmen, 
etc. The susceptibility of the carnivora to the disease is very much 
less than that of the herbivora. It is claimed that not only direct 
inoculation may produce the disease, but that it may be extended by 
the medium of flies and other insects. More recently it is claimed 
that food, drink, and even inspired air may be the medium by which 
the disease is conveyed. 

Pathology. — Since the first investigations reported by Davaine to 
the French Academy in 1864, Pasteur, Klebs, Koch, Carneviu, aud 
others have fully demonstrated that splenic fever is solely due to the 
multiplication in the blood and tissues of a rod-shaped bacillus, the 
bacillus anthracis, which is always motionless. Under culture the 
bacilli may develop long filaments, many times larger than the 

1 A chromolithograph exhibiting the peculiar features of the malignant pustule in the neck, will be 
found in the British Med. Journ. of June l:i, 1SS4, illustrating a paper by Mr. Morrant Baker. 



PUSTULA MALIGNA. 207 

original rods, with a distinct sheath about a protoplasmic cylinder, 
which after segmentation furnishes oval and shining spores. These 
have been cultivated again and again, with re- 
sulting germs that have produced the disease FlG - 3C - 



artificially in the lower animals. 

The pathological anatomy of the malignant «$ . ^ 

pustule is that of carbuncle with the added V ««»«os) 

fact that specific bacilli and spores are abun- (i ^^Ai #?'? 

dantly present in the blood and debris of / t$\ ^'# . 

tissue. *..*», ^ &%t^ 

In establishing a diagnosis, care must be {JfJL*^ $%# 
taken to avoid one source of error. Malig- #'*■*■ " ftao<> 
nant pustule in man is not of frequent occur- 
rence in this country, but occasionally various Malignant *™ tul ° bacim and 

" ' . - . J . pus corpuscles. About X 300. 

cutaneous eruptions are induced upon the 

hands, after contact with animals or hides upon which chemical solu- 
tions have been applied for the destruction of lice. These solutions 
usually contain arsenic, corrosive sublimate, or other substances capa- 
ble of exciting a localized dermatitis. 

The treatment is to be conducted on the principles of general thera- 
peutics. Popper, 1 an Hungarian physician with a large experience 
in malignant pustule, reports success by deep excision of the lesion, 
extending the operation to the subcutaneous connective tissue. This 
has always proved successful when practised before the occurrence of 
general symptoms. 

A number of other authors have had similar successful results 
after excision. Pitts, for example (Brit. Med. Journ., March 19, 
1887), reports two successful excisions of malignant pustule in the 
case of brothers. Hebra was not in favor of the early cauterization 
of the malignant pustule, and it may be considered as a questionable 
method of procedure. 

A grave case of malignant pustule is recorded, 2 in which recovery 
ensued after the hypodermatic injection of the tincture of iodine. 
Three syringefuls of the pure tincture were deposited beneath the skin 
at the periphery of the diseased surface, and lint soaked in the same 
was applied over the slough. Internally, fourteen drops of the 
tincture (1.) with three grains (0.26) of the iodide of potassium, were 
also administered. Normal cicatrization followed in this and six 
other cases recorded. 

Crucial incisions with the free application afterward of pure car- 
bolic acid have been followed by good results. Mr. Baker, of 
London, reports rapid and complete relief after excision, and the free 
use of iodoform. Internally, the hyposulphite of sodium and quinine 
are successfully employed. The febrile, typhoid, and adynamic 
features of the disease are to be treated in accordance with the recog- 
nized principles of general medicine. 

i Ctbt. f. Chir., 1881, No. 33. 2 Arch. gen. de Med., Feb. 1883. 



208 DISEASES OF THE SKIX. 

Herpes. 

Gr. kprreiv, to creep. 

Herpes is an affection of the skin characterized by the occurrence of one or 
more vesicles rilled with a clear serum, disposed in groups, limited to a 
certain region of the body, and pursuing a definite career within a relatively 
brief period of time. 

The term herpes is unquestionably responsible for a great deal of 
the confusion which has existed with respect to contagious disease. 
By the ancients it was employed, as its etymology suggests, to desig- 
nate a disease creeping or extending gradually over the surface or 
within the substance of the skin. By several more modern authors 
the term has been employed in a generic sense in a futile attempt to 
distinguish a series of so-called " herpetic diseases," and even her- 
petic diatheses from those of a different complexion. 

The significance which attaches to the word in the minds of the 
dermatologieal authors of this day, is exceedingly simple, and is 
limited to the features conveyed in the definition given above. It 
will be seen that the description thus embodied is largely that 
of herpes' zoster, an affection which is in this work considered 
separately. 

Symptoms. — The disease is declared by the occurrence of millet- 
seed to coffee-bean sized vesicles, single or relatively few in number, 
and in the latter case grouped, occurring as epiphenomena of a 
general febrile process, or as symptoms of an idiopathic disease. 
The lesions are usually short-lived, surviving but for a few days, 
and are filled with a clear, serous fluid which may become lactescent. 
After accidental or spontaneous rupture, there is left a slightly 
tumid, superficial excoriation, which at times is characterized by a 
circumscribed hyperemia, slight infiltration, or oedema of the base 
and periphery. The subjective sensations are not usually severe, 
varying between moderate pain, itching, and heat. There are occa- 
sionally precedeut chill and pyrexia, but no persistent lesiou-relics 
result from complete involution. 

Herpes Facialis. — About the lips, mouth, and alas of the nose, 
rarely upon any other portions of the face, lesions occur singly, or iu 
a group, possessing the characters described above. Their frequency 
about the lips has determined the title Herpes Labialis, under 
which they are described by several authors. The tongue, buccal 
membrane, palate, and larynx may participate in the morbid process; 
and the lesions in such moist situations are represented by isolated or 
grouped, dark-grayish patches of epithelium, which are sensitive and 
exfoliate. The functions of the mouth in articulation and mastication 
are thus rendered painful. The disease is common in acute pneu- 
monia, malarial and enteric fevers. In these cases, as Kaposi has 



HEEPES. 209 

shown, the occurrence of the eruption by no means augurs favorably 
in every instance, as a fatal result may nevertheless follow. 

Often the lesions coalesce, forming a pea-sized bleb in an irregular 
line of elevated epidermis, spreading along the vermilion border of 
the lip and distended with a clear serum. The burning and itching 
sensations which accompany the lesions are often marked and dis- 
tressing. In the course of two or three days, thin crusts form whose 
exfoliation terminates the disorder. 

The connection betweeu labial herpes and rigors has long been 
recognized, though particular attention has been directed to this 
relation by Hutchinson and Symonds. Beside the trophic disturb- 
ances of this nature, traumatism, exposure to solar heat, unusual 
fatigue, a simple coryza, exposure to a cool draught of air, and tem- 
porary gastric disturbances may suffice to induce the disease. There 
are patients who can produce the lesions at will by tickling the lips 
with a feather. There is in some individuals an unquestionable 
susceptibility to the disease. The disorder is always short-lived 
though often recurrent; and the superficial crusts which terminate 
the process are never followed by scars. 

Herpes Progenitalis. — This disorder, also termed Herpes Prse- 
putialis, is characterized by the appearance of one or a group of 
transitory vesicles occurring on the inner face of the prepuce, espe- 
cially upon its upper limb, on the glans, the balano-prseputial sulcus, 
and the adjacent integument; in women, on the hood of the clitoris, 
the labia minora, the inuer face of the labia majora, and adjacent 
surfaces even as far removed as the buttocks. 

There is usually precedent pruritus or a sensation of heat, followed 
by the appearance of one or several pin-head sized vesicles seated 
upon a tumid and hypersemic base. Within the preputial sac the 
lesions may either rupture at an early moment, or assume the features 
described as presented upon the mucous membrane of the mouth. 
The resulting oedema of the prepuce is often displayed in an annular 
tumefaction encircling the glans, while the labia minora perceptibly 
project from the general vulvar plane. In these localities the floors 
of ruptured vesicles are particularly liable to be irritated (coitus, 
caustic, etc.), and then pus and even blood may be exuded with much 
angrier excoriation and resulting crusts of darker shade. In the 
course of a few days even these crusts fall, and the disease is at an 
end. Recurrence is common. 

Often a first attack of herpes in the male results in an extraordi- 
nary sensitiveness of the balano-prseputial membrane, which persists 
for more than a year. The patients are usually middle-aged men, 
married, and virgin as to venereal antecedents. The membrane is then 
tumid, tense, slightly glazed, and dark red to dark purple in hue. 
Upon any undue sliding of the prepuce over the glans, a very super- 
ficial fissure occurs, whence a drop of serum oozes. The membrane 
becomes so sensitive that the passage of the finger over it is resented 

14 



210 DISEASES OF THE SKIX. 

as though the conjunctiva had been touched. Unusual friction by 

the clothing or the use of a stimulating lotion, is followed by intense 
pain and aggravation of symptoms; and the price of coitus is a 
week's resl in bed. 

Naturally the diagnosis of herpes progenitalis is between chancroid 
and chancre. The latter will be manifested by its induration, its 
period <>f incubation, and its characteristic double inguinal adeno- 
pathy. The chancroid, whether in pustular form or inoculated 
abrasion, is ah oriaine ulcerative in tendency, capable of auto-inocu- 
lation, and often accompanied by sympathetic, inflammatory, or 
virulent bubo of one side. Balanitis, with its puriform secretion and 
superficial patches of reddened epithelium, is readily distinguished 
by its symptoms, though the two disorders frequently coexist. 

Tin; practitioner should never forget that the patient who exhibits 
an herpes of the genital region to-day may have been inoculated at 
the site of these lesions which may to-morrow or later take on the 
chancrous modification. The rule to be followed, then, is very 
simple. No individual with a progenital herpes can be assured of 
immunity against syphilis, till the longest period of incubation of 
the syphilitic chancre has elapsed since the date of last suspected 
exposure. 

Herpes progenitalis is almost universally the result of naturally 
or unnaturally induced sexual erethism. Its occurrence in an indi- 
vidual virgin as to such antecedents may be due to the causes efficient 
in the production of herpes facialis. Unna, 1 in an interesting paper 
on the subject, has conclusively shown that, though relatively rare 
in chaste women, it is of common occurrence in prostitutes. 

Messrs. Diday and Doyou, 2 who have given special attention to 
the subject, believe that true herpes of the genital region is always 
of the recurrent type, and well marked by its special course, career, 
and consequences. All others of a false type are divided by them 
into [J] an irritative form, seen in women as the result of vaginal 
discharges, sexual irritation, etc.; [2] a pseudo-membranous or diph- 
theroid form, also occurring for the most part in women, vesicular 
and even bullous in its lesions, whose rupture is the signal for the 
pseudo-membranous transformation; [3] a neuralgic form, which is 
merely zoster of the genital region. 

Treatment. — The milder forms of herpes occurring about the lips 
and genitalia require the simplest treatment. Sponging with pure 
water, as hot as can be comfortably tolerated, is best followed by 
local use of a weak lead lotion, rose ointment, or zinc salve. About 
the lips it is well to protect the lesions with flexile collodion or isin- 
glass plaster. Occurring upon the genital region, the lesions are to 
be protected by the interposition of a pledget of lint or a borated or 
salicylated dusting powder. As a rule, ointments are unsuited for 
the moist mucous surface of the genitals, the odorous emanations 

1 Jonrn. of Cntan. and Ven. Dis., Aug. 1S83. 

2 Les Herpes Genituux, Paris, 18SG. 



HERPES. 211 

from most diseases of such parts being retained disagreeably by all 
grease-containing compounds. Lotions answer a far better purpose, 
and these may be made stimulant with alcohol; astringent with 
tannin, the sulphate of zinc, or the sulphate of copper; painless with 
opium or cocaine; and antiseptic with carbolic acid or corrosive sub- 
limate. Prophylaxis by the local use of aromatic wine, or tannin 
and brandy, with continence, is a matter of importance. 

Herpes Iris. 

The behavior of the lesions in herpes iris differs somewhat from 
that just described; and this has led several authors to consider the 
affection as a separate and distinct disease. As there is, however, 
some doubt respecting the question whether herpes iris should not be 
relegated to the domain of erythema multiforme, it is assigned a 
provisional position in this connection. 

The symptoms at the onset are the occurrence of one or several 
vesicles or vesico-papules, which pursue their usual rapid career in 
two or three days. Upon the hyperpemic ring which surrounds these 
a second and even a third and fourth circlet of similar lesions form, 
each pushing the areola further to the periphery of the patch. The 
older are in full retrogression while the newer are in process of 
evolution; and the red blush which surrounds the earlier is under- 
going color-changes from vivid to paler hues, while the zone of the 
latest vesicles is assuming its intensest shade. The lesions are pin- 
head to pea-sized, rather persistent and firm ; and terminate more 
often by resolution than by rupture and crusting. The concentric 
and parti-colored rings may make up a single patch an inch or more 
in diameter, or several such patches may form upon the surface of the 
integument. In the latter case the central disk of some of the patches 
will be seen to be made of confluent lesions. The eruption is most 
commouly situated upon the extremities, especially over the dorsum 
of the hands and feet, in which situation, especially when symmetri- 
cally developed, it is always, according to Kaposi, more nearly allied 
to erythema multiforme. It is, however, also rarely seen upon the 
face. The subjective sensations produced are usually trifling. Atyp- 
ical forms occur where the lesions are imperfectly developed from 
papules, and also where, in consequence of an unusual exudation of 
serum, bullae appear. 

The points in which herpes iris most resembles erythema multi- 
forme are : the variegation of the tints in the peripheral integument 
(whence the name, iris) ; its localization upon the extremities chiefly ; 
its occasional symmetry ; its frequency in young adults ; and its 
tendency to occur in the spring and autumn. Per contra, herpes 
iris differs from other forms of herpes ; in the absence of a precedent 
febrile state or neuralgic pain ; in its avoidance of regions near the 
mucous outlets of the body (prseputial orifice, vagina, mouth) ; and 
in the behavior of the vesicular lesions after attaining their full 
development. 



212 DISEASES OF THE SKIN. 

The affection is evidently one upon the border-line between herpes 
and erythema multiforme ; and might be properly considered under 
either title. Its existence is another evidence of the impossibility of 
drawing hard and fast lines between all the clinical symptoms pre- 
sented by different diseases. 

It can scarcely be mistaken for other affections, in consequence of 
the elegance with which its lesions are disposed. Pemphigus 
simplex and pemphigus foliaceus differ decidedly in their career, 
however much they may, at the outset of exceptional cases, present 
certain points of resemblance. 

The affection tends to spontaneous recovery, and requires no treat- 
ment. A dusting powder may be applied over the surface, if need 
be, to protect the lesions from accidental rupture. 

Herpes Gestationis, or Pemphigus Hystericus, is a name which 
has been employed to designate erythematous, papular, vesicular, and 
bullous lesions, accompanied by marked pruritic and burning sensa- 
tions, occurring usually upon the extremities, but also upon other 
parts of the body. The subjects are usually pregnant or hysterical 
women, who are said to exhibit recurrent attacks in successive condi- 
tions of pregnancy or neurotic disorders. Personal experience has 
led the author to accept fully the view of Duhring, that this disorder 
should be included under Dermatitis Herpetiformis. 

Herpes Zoster. 

Gr. suoryp, a girdle ; Shingles, Lat. cingulum, a girdle. 

Herpes Zoster is an acute exudative affection of definite career, characterized 
by the occurrence of groups of firm and distended vesicles, preceded, accom- 
panied, or succeeded by neuralgic sensations, usually monolateral in distri- 
bution, and followed in some cases by persistent cicatrices, the cutaneous 
symptoms being always limited to an area of the skin supplied by a twig 
of one or more of the cranial or spinal nerves. 

Symptoms; — This disorder is also termed Shingles, Zona, and Zoster. 
The eruption is usually preceded, for a period lasting from a few 
hours to days and even weeks, by malaise or ueuralgic sensations 
of moderate or severe intensity. These sensations are usually 
limited to the area of the integument subsequently or coincidently 
displaying cutaneous lesions; but there are exceptions to this rule, 
as the pains are at times experienced elsewhere. Often, though 
limited to the region about to be attacked, they occur where pain is 
experienced in other neuralgias, at the points indicated by Romberg 
as corresponding to the regions where cutaneous brauches are given 
off by the nerve trunks. 

According to Fabre, the essential lesion, always present even when 
vesicles are not seen, is the first macular efflorescence of the disease. 
This appears in the form of vivid and brilliant-red erythematous 
macules, groups of which, from six to ten in number, appear in the 



HERPES ZOSTER. 213 

tract supplied by the affected nerve. The vesicles (which are gener- 
ally regarded as more characteristic of the disease) appear afterward 
in from a few hours to a day or more, springing from the macules, 
and are accompanied by a sensation of heat. These typically perfect, 
isolated vesicles vary in size, from a rape-seed to a coffee-bean. They 
appear in groups corresponding to the groups of the macules, from 
eight to a dozen in a single cluster, and appear successively, the indi- 
vidual members of each attaining maturity simultaneously in about 
one week, while the succession of others may prolong the period of 
efflorescence to an entire month. 

The lesions, when fully developed, exchange their early limpid 
contents for those of a lactescent or puriform character. They project 
well from the widely hypersemic base from which they spring; are 
tense from complete distention ; and have no tendency to spontaneous 
rupture, so firm is their roof-wall. When abundant, they may 
coalesce. Involution is accomplished by desiccation, and the forma- 
tion of yellowish-brown crusts, whose fall is succeeded in certain 
cases by indelible scars. 

Several variations from the type thus described require notice. 
The vesicles may be few and typical ; numerous, abortive, and transi- 
tory ; or differ in type as they may be transformed into veritable 
pustules or bullge, or become filled with blood from capillary haemor- 
rhage. In the latter event there is still further departure from type 
in their tendency to spontaneous rupture and subsequent ulceration. 
According to Kaposi, it is in such cases only that cicatrices form ; 
but this statement, in view of many clinical observations, must be 
accepted with reserve. 

Authors have established a number of clinical varieties of the 
disease merely differing as to symptoms, such as acute febrile, apyretic, 
subacute, and even chronic and recurring forms. A bluish appear- 
ance of the eruption in some parts has suggested the name " black 
herpes ;" blood in the vesicles, a hemorrhagic form ; and the occur- 
rence of gangrene has added an additional distinguishing term. 

The anomalies of nervous significance are : extraordinary persistence 
of neuralgia after the involution of the cutaneous lesions ; neuralgia 
of an intense and intolerable severity at any period of the disease ; 
painful anaesthesia of the skin ; paretic and paralytic phenomena with 
resulting muscular atrophy ; and, in zoster of the head, dehiscence of 
teeth and hair. 

The vesicles of herpes zoster are always produced in the areas of 
integument supplied by sensory nerves proceeding from the cerebro- 
spinal tract, a circumstance which explains their usual imitation to 
a single lateral half of the body. This limitation is rarely observed 
exactly at the median vertical .line of the body, as a few lesions can 
usually be seen surpassing this boundary. The terms zoster capitis, 
zoster brachialis, zoster occipito-cervicalis, etc., are used to distinguish 
the special regions involved in the disease. 

The fact that the majority of all cases are due to disease of the 
ganglionic nervous system and not to disease of the spinal cord, 



214: DISEASES OF THE SKIN. 

explains the more frequent occurrence of zoster in the upper portion 
of the body. 

Individuals arc commonly subject to but one attack of herpes 
zoster in a lifetime, though, as usual for all general laws, there are 
the few exceptions which prove the rule. The same may be said of 
double attacks, those involving simultaneously the two lateral halves 
of the body, instances of which are occasionally recorded. These 
may be complete and symmetrical, or multiple and not symmetrical; 
or bifid, when there is simultaneous involvement of several branches 
of one nerve or of several nerves. 

Barensprung recognized the nine varieties of this disease named 
below, the difference in each having a purely local significance. 

Zoster Capillttii depends upon involvement of the second 
branch of the fifth pair of nerves, and its lesions occupy the anterior 
and posterior portions of the scalp. 

Zoster Frontalis occurs in the area supplied by the supra- 
orbital nerve, which springs from the first branch of the trigeminus. 
Its lesions extend from the upper eyelid to the vertex, and are spread 
in a fan-shaped figure over one-half of the brow, forehead, and scalp. 

Z< »ster Ophthalmicus may be a severe and dangerous manifes- 
tation of the disease, being often complicated by agonizing neuralgia, 
formidable involvement of all parts of the eye even resulting in 
panophthalmia, ulcerative keratitis, pyaemia, meningitis, and death. 
Typical cases of zoster of this region may not, however, exhibit a 
single outward symptom of the disease. 

Zoster Facialis depends upon involvement of the sensory nerve- 
fibres of the trigeminus distributed to the face, its lesions being 
displayed over one cheek, the side of the nose, the half of the lip, 
or of the chin. The facial and seventh nerves may be chiefly 
affected. Care must be taken in cases of this variety not to con- 
found the disease upon the nose with acne, or painful tertiary syphil- 
itic lesions, errors which have occurred. When the lower jaw is 
involved, there may be severe toothache, dysphagia, and fall of the 
teeth with great resulting deformity. 

Zoster Nuch^e seu Collaris occupies the region extending 
forward from the cervical vertebrae to the clavicle, or upward toward 
the occipital region and the auricle. 

Zoster Brachialis occupies the region from the last cervical and 
first dorsal vertebras over the supra-spinous scapular region and the 
contiguous portion of the uper arm. Rarely, even the skin of the 
fingers, and that over the first and second ribs is involved. It is 
a common and usually mild form of the disease, and characterized 
by a peculiar isolation of the vesicular groups. It occurs also with 
lesions of exclusively brachial distribution. 



HERPES ZOSTER. 215 

Zoster Pectoralts is the most frequent form of the disease, from 
which its common name "shingles" originated. The eruption occurs 
below the first dorsal, covering the skin of the thorax as far as the 
lumbar vertebrae, extending from the spinal column behind to the 
sternal regiou in front. Two, three, or more of the intercostal nerves 
in this region are commonly involved, and the neuralgia resulting has 
been frequently mistaken for the pain of a pleurisy. Children are 
more apt to display this than any other variety of zoster. 

Zoster Abdominalis. — The area here involved extends from the 
lumbar vertebrae to the median line of the abdomen. It is usually 
much less pronounced in its features, and the exanthem less abundant 
than in the variety of the disease last described. When constipation 
exists, defecation may be attended with considerable pain. 

Zoster Femoralis covers the buttocks and sacrum, and extends 
along the thigh, sweeping from behind forward and from above 
downward as far as the popliteal space ; in some cases involving the 
leg and foot. The penis, scrotum, labia, vestibulum vagina, and 
anus may then exhibit unilaterally arranged vesicles. 

The scars left by zoster are characteristic. Not only are they 
limited to the seat of the original disease, but they have a peculiar 
indented look, as if made by a nail-sett and hammer. They are 
particularly angular in outline, and do not exhibit the dead-white 
color of many cicatrices. 

Etiology. — Herpes zoster occurs in both sexes, and in the young as 
well as the old, though it is rarely seen among infants. It seems to 
be somewhat under the influence of the seasons, as cold and damp 
weather serves to increase its frequency in those susceptible to it. A 
large list of other depressing agencies are named as effective in its 
production, such as : certain poisons, carbonic acid gas, belladonna and 
atropine (Mackintosh), arsenic (Baker, Dyce Duckworth, Hutchin- 
son); pyaemia, carcinoma, fever (Gerhardt), pulmonary inflamma- 
tions (including phthisis), septicaemia, haemorrhages, traumatism, and 
malaria. Inasmuch as no one of these causes can be cited as cer- 
tainly effective in all cases, it can merely be said that any influence 
sufficient to induce inflammation of a sensory nerve or its ganglion 
may be followed by the objective signs of the disease. 

Pathology. — The researches of Barensprung, Rayer, Wagner, 
Charcot, Kaposi, and others have demonstrated with sufficient clear- 
ness that in zoster there is always, at some point in the corresponding 
nervous tract (cerebral or spinal centres, ganglia, or the nerves them- 
selves), pathological changes. These are : enlargements, haemorrhagic 
effusion, separation, softening, or destruction of the nervous bundles, 
with hyperaemia, infiltration, and multiplication of the elements 
which surround the latter. 

Sometimes the ganglia and nerves are both reddened and swollen 
at the site of the inflammatory affection ; at other times the ganglion 



216 DISEASES OF THE SKIN. 

alone is large and soft, or fatty from metamorphosis of its cells. 
According to Curshmano and Eisenlohr, the process may begin in 
the bloodvessels of the nerve-sheath, as well as the peri-neural con- 
nective tissue, the nerve substance being quite intact. This is termed 
acute uodose peri-neuritis, as small nodules were recognized by them 
in one case along the cutaneous branches of the axillary nerve. 
Lassar, 1 in a post-mortem examination of three cases, found the 
nerves thin, flattened, and of a transparent reddish-gray color con- 
tra.-! ing with the normal white. There had been desquamation to 
the extent of replacing the normal structure with connective-tissue 
elements. Similar changes wcw recognized in ganglion cells and 
fibres. 

Fig. 37. 

d 



^c:g^w 



a 4,5 



t 



c I 



F-__f- 



Longitudinal section of the third spinal ganglion of the right lumbar region from a case of lumbo- 
inguinal zoster. 0,0, ganglion, the black points correspond with pigmented ganglion cells, the dark 
lines to engorged vessels; a,b,c,d,e, fatty tissue surrounding the ganglion ; 6,6, nerve filament divided 
longitudinally at the points of entrance and exit; at c,c, divided perpendicularly. (After Kaposi.) 

According to Biesiadecki and Haight, the cutaneous lesions origi- 
nate in the deeper portions of the rete, precisely as in other vesicular 
diseases. The exudate from the hypersernic corium, especially its 
papillary layer, presses upward into the rete, the epithelia of which 
are thus separated and vertically elongated. The serous exudation 
finally reaches a point where the horny layer is forcibly raised from 
its bed to form the roof of the vesicle. The mechanical destruction 
of the papillary layer of the corium by the hemorrhagic or purulent 
contents of the lesions results in a solution of continuity, which is 
healed only by granulation and the necessary formation of a cicatrix. 

Robinson, also, studying the same phenomena in the skin, finds 
the epithelia lengthening into bands by tension, the lacunas between 
them distended with serum and a few round cells. Often the vesicles 
form about the hair-sacs. As the exudation increases, the rete cells 

i Ctblt. f. d. Med. WisseiiBch., Dec. 1883. 



HERPES ZOSTER. 217 

are progressively separated, and finally discovered free in the exuded 
fluid, though some, in changed form but still connected, may be 
found in the upper part of the vesicle. Except at the margin, the 
mucous and horny layers are separated by the exudation. At first 
many-chambered, the vesicle represents finally a single chamber filled 
with serum containing rete-cells and a few pus-cells, the latter in- 
creasing in number as the vesicle changes its type. Its base at first 
rests upon the lower portion of the mucous layer; later, upon the 
corium itself where all signs of papillse are absent. In the vicinity 
of the vesicle the papillse and corium are infiltrated, and the vessels 
dilated, this peripheral change not extending deeply into the corium. 
Beyond this area, however, which is infiltrated in a columnar-shaped 
region, usually about a hair-follicle deep in the subcutaneous tissue, 
Robinson has recognized a peri-neuritis characterized by a round- 
celled infiltration within and around the neurilemma. 

Diagnosis. — The vesicles of herpes zoster are not rarely confounded 
with those of eczema. But the distinction between the two is always 
very readily established. In eczema there is itching but no neur- 
algia; vesicles which tend to rupture spontaneously, and never per- 
sist as in zoster; the eczematous lesions are also smaller, more acu- 
minate, and rarely distinctly limited to the lateral half of the body. 
Herpes simplex is frequently recurrent, herpes zoster almost never; 
herpes simplex is exceedingly liable to spread around the mucous 
outlets of the body, and on either side of the latter, while zoster only 
reaches such regions after exteusion from other parts, and is then 
almost invariably monolateral. Its lesions are, moreover, never 
grouped in the concentric circles of herpes iris. 

Treatment. — The indications to be met in the local treatment of 
herpes zoster are the protection of the vesicles from rupture, and the 
relief of pain. These ends are best accomplished by thickly dusting 
the entire surface affected, with an opiated powder, such as Anderson's 
powder, with the sulphate of morphia, two grains (0.133) to the 
ounce (32.) ; lycopodium with powdered opium, etc. Rupture of the 
lesions should never be practised. Over the whole should be gently 
laid a sheet of soft lint or antiseptic cotton, its meshes also filled 
with the powder, and a bandage, when practicable, smoothly bound 
over the whole. In the milder cases, nothing more than this is 
needed from first to last. In others, where the lesions have rup- 
tured aud their bases undergone erosive or ulcerative changes, the 
oleated lime-water with zinc oxide, belladonna and opium or morphia, 
should be applied and covered with the Lister protective. Carbolated 
and anodyne ointments may also be used, especially toward the latter 
part of the history of the case. 

Lotions may be employed of lead-water and laudanum, or the 
"lead and opium wash." Van Harlingen recommends half an ounce 
(16.) each of the precipitated zinc carbonate, powdered zinc oxide, pow- 
dered starch, and glycerine, shaken up in half a pint (256.) of water. 

Duhring speaks well of collodion with morphia, in the strength of 
ten grains (0.666) to the ounce (32.). Kaposi warns against the use 



218 DISEASES OF THE SKIN. 

of the diachylon ointment. Generally, it may be said that ointments 
should be the lasl resorl ; but those containing from ten to twenty 

grains (0.66— 1.33) of the aqueous extract of opium or belladonna to 
the ounce (32.) will at times give relief from pain. The oleate of 
cocaine and menthol have been used locally with great advantage in 
meeting the same indication. 

X<> remedy, for internal use, is known to have the power of 
aborting or shortening an attack. Quinine is certainly indicated and 
does no harm; but quinine and strychnia alike in full doses have 
proved quite inefficacious. Other remedies employed are the phos- 
phide of zinc in one-third of a grain (0.022) doses, repeated every 
three hours, and, if indicated, in combination with one-sixth (0.011) of 
a grain of the extract of mix vomica; arsenic (Kaposi) ; and the tonics 
in general. Anodynes, orally or by hypodermatic injection, are often 
indispensable. Inasmuch as many patients consider the attack a 
trivial matter, it is of some consequence that they be warned of the 
possibilities of the future and be confined to an apartment of equable 
temperature where they are not exposed to atmospheric changes. 
This is of special importance in all the zosters of the face. A skilled 
oculist should be consulted in all eases involving the eye. 

Prognosis. — Zoster usually runs a benign course, but it should 
never be forgotten by the practitioner that the prognosis may be in 
the highest degree grave. Many severe cases have occurred, where 
the patients, after years of intense suffering, have resumed the occu- 
pations of life, physical wrecks of their former selves, their faces 
indented with profound scars, and the vision of one eye impaired or 
utterly ruined. Rarely the termination is fatal. 

Dermatitis Herpetiformis. 

Dermatitis Herpetiformis is a rare but well denned febrile disorder, character- 
ized by the appearance upon the skin, of multiform lesions, differing in 
different cases, macular, papular, vesicular, pustular, or bullous in type, 
attended by subjective sensations of itching and burning, the disease at 
times being grave in character and fatal in termination. 

Dermatitis Herpetiformis should be named Dermatitis Multiformis, 
as the latter term is more descriptive of its phenomena. It is a 
malady which, in oue form or another and under different titles, has 
long been recognized and described. The credit, however, of clearly 
establishing its identity, and of recognizing one process as differently 
expressed in the several observations of others, is largely due to Dr. 
L. A. Dnhring, of Philadelphia. 1 

It should be noted, at the outset of the study of this malady, 
that, its identity as a special pathological process having been only 

i Dermatitis Herpetiformis; its relation to so-called Impetigo Herpetiformis. Amer. Journ. of the 

Med. Sri., October, lxs-i. 

Dermatitis Herpetiformis. Case of, caused by nervous shock, etc. Ibid., January, 1885. 

Case of Dermatitis Herpetiformis, illustrating the pustular variety of the disease. Journ. of Cutan. 
and Veil. Dis., vol. i., No. 8. 

Case of Dermatitis Herpetiformis with peculiar gelatinous lesions. The Med. Xews, March 7, 1885^ 

Notes of a Case of Dermatitis Herpetiformis, etc. N. Y. Med. Journ., November, 1884. 

A Case of Dermatitis Herpetiformis (Bullosa) N. V. Med. Journ.. July, 1884. 



DERMATITIS HERPETIFORMIS. 219 

lately established, much investigation is yet required before settling 
definitely many of the interesting questions it presents for considera- 
tion. Duhring regards its vesicular and bullous forms as identical 
with "herpes circinatus bullosas" (E.Wilson); "pemphigus pruri- 
gineux" (Hardy); "herpes gestationis" (Milton, Bulkley, and others); 
"pemphigus" (Klein); "pemphigus circinatus" (Raver); "herpes 
phlyctrenodes" (Gibert); "pemphigus aigu pruriginosus" (Chausit); 
"herpes iris" (Jarish); "fatal pemphigus-like dermatitis" (Mayer); 
"peculiar skin eruption recurring during pregnancy" (Oswald); 
"bullous eruption of a peculiar character" (Leigh); "pemphigus 
compose" (Devergie); and "hydroa" (Jones, Bulkley, and others). 

Symptoms. — The disease is usually announced by malaise, sensa- 
tions of chilliness, decided rigors or alternations of cold and hot sensa- 
tions, with systemic disturbances. The skin usually is then the 
seat of pruritic or burning sensations followed in the course of from 
twelve hours to two days by the appearance of the exanthem. This 
may be macular, papular, tubercular, vesicular, pustular, or bullous, in 
type; combinations of these lesions recurring in every variation. 
The lesions may be cutaneous, muco-cutaneous, or mucous in situation. 

The macular form of eruption appears in small-coin to palm-sized 
patches, irregularly rounded, coalescing, well or ill-defined as to 
outline, and slightly raised, suggesting the lesions of erythema multi- 
forme or urticaria. Imperfectly defined maculo-papules, papules, and 
papulo-tuberculous lesions, varying in shape, size, and firmness may 
also spring from or be intermingled with the reddish maculations 
described above. 

In typical development the disease, however, presents cutaneous 
symptoms of herpetic type. Flat, slightly elevated, hard, angular, 
irregularly outlined vesicles may appear, pin-head to bean-sized, 
tensely distended with their contents. They may be pale-yellow or 
darker in color, and with or without areolae. When bullae form, they 
may be sparse or plentiful, and bean- to egg-sized, with cloudy, lactes- 
cent, hsemorrhagic or purulent contents. Pustules, when present, 
are single or clustered, pin-head to bean-sized lesions, flat, and 
surrounded by a livid areola. When evolution is complete, segments 
of rings, or distinct rings of new punctate or large pustules surround 
those first formed, which in less than a week rupture and become 
covered with a crust, the ' latter being flat, adherent, and yellowish, 
greenish, brownish, or blackish in color. When there is coalescence, 
a large coin-sized pustule and crust may result, and even large 
patches of such coalesced lesions. The lesions may number from a 
score or fewer to hundreds. 

The imprint of the cutaneous symptoms is multiformity and 
recurrence. Vesicles, pustules, and bulla?, without order or regularity 
of evolution or recurrence, appear at one and the same time, in 
rapid or slow succession, and without fixed intervals of appearance 
for months at a time. Generally, however, a prevalence of one 
special type of lesions may be noted during a single period of out- 
break or recurrence. This prevalence is in the direction generally 



220 DISEASES OF THE SKIN. 

of lesions of an herpetic type, viz., the vesicular and the bullous, iu 
variously sized patches with a tendency to coalesce. 

A.S a result of the conditions described above, a peripheral new 
formatioD of lesions tends to produce marginate patches where 
grouping occurs, the groups, however, being interspersed with dif- 
fusely disseminated lesions of* various types. The irregular, angular, 
or stellate forms of the lesions containing fluid, are highly suggestive. 
Pigmentation and infiltration of the skin are commonly noticed. 
The subjective sensations of burning, increase and diminish as cuta- 
neous lesions are multiplying or disappearing. The pruritus is in 
some cases more severe than in eczema, and the traumatisms of 
scratching add greatly to the multiform features of the disease. 

The disease lasts for months and years. Duhring reports some 
cases lasting for five to fifteen years, with periods of relative or entire 
immunity. 

In one of Duhring's cases there were thumb-nail sized, raised but 
flat, golden-yellow colored lesions, of very firm consistency, con- 
taining a similarly colored, thick, consistent, gelatinous pulp. The 
author states that he has observed them before in several cases of 
this same disease. 

When the oral cavity is invaded, pustules and bulla? appear upon 
the mucous surface which, being macerated and sodden, rupture, 
leaving raw erosions and unhealthy looking, even sloughing patches 
of mucous membrane. Crusts form about the nares aud lips, and 
the stench of the patient becomes intolerable. In the same way the 
vulva, anus, and prepuce may be surrounded by vesicular and bullous 
lesions which form also on the mucous surfaces adjacent and pursue 
a course similar to that recognized in the mouth. 

In grave cases, as the skin symptoms exhibit a marked aggrava- 
tion, the systemic condition changes for the worse. After a low 
fever alternating with chills and accompanied by progressive cachexia 
and emaciation, an intermittent diarrhoea or pneumonia may close 
the scene. The repulsive appearance of the patieut at the last is, in 
severe cases, as formidable as in the fatal issues of confluent variola 
or severe pityriasis rubra. 

The etiology, pathology, and proper mode of treatment of this dis- 
ease are not yet fully understood. In some cases disorders of the 
nervous system must be admitted as efficient in its production. 
Duhring reports a typical case following nervous shock. One of my 
patients had lost a number of children by accident. The disease 
occurs in early and middle adult life in both sexes, though in women 
decidedly oftener than in men; and, among the former, preferably 
among those in the puerperal and pregnant states. Unquestionably 
the phenomena of the disease in the later stage of fatal cases are 
septicemic in origin. 

Internal treatment in general has been directed to meet the indica- 
tions presented. Thus, quinine, the mineral acids, ergot, saline 
laxatives, iodide and bromide of potassium, arsenic, aud chloral, 



PSORIASIS. 221 

have all been administered without appreciable effect upon the dis- 
ease. Locally, carbolic acid, tar lotions, the unguentum diachyli 
albi of Hebra, mercurial and zinc salves have all been employed. 
One of Duhring's patients experienced great relief from the use of 
a sulphur ointment. Two of my patients were treated with very 
great comfort to the end in the continuous warm-water bath. 

The prognosis is always doubtful and generally grave. It is not 
certain that the disease is ever completely relieved. A male patient, 
seen by me in consultation and then presenting the typical features 
of the disease, was reported well after one year. 

Psoriasis. 

Gr. tpupd, the itch.. 

Psoriasis is a cutaneous disease, acute, or, more usually, chronic in course, 
characterized by masses of whitish, lustrous, and adherent scales, in pin- 
head sized agglomerations upon the surface of the skin, or in larger disks 
resting upon circumscribed, usually circular and reddened patches of 
epidermis, which are readily made to bleed. 

Symptoms. — In Psoriasis, also termed Lepra, Alphos, and Psora, 
the primary lesion is a punctiform macule of reddish-brown tint, 
always, at the earliest moment of observation, covered with a deli- 
cate, whitish, epidermic scale. When this is removed even by gentle 
scraping, one or more minute droplets of blood exude from the points 
beneath which lie the vascular papilla? of the corium. When several 
or many such small points are visible upon the surface, the disease is 
called Psoriasis Punctata. 

Should the disease progress to fuller development, patches of larger 
size form, always with a definite contour, very slightly elevated above 
the general level of the integument, and covered with whitish, 
mother-of-pearl-colored scales in abundance. When these are about 
the size of drops of water, the disease is termed Psoriasis Guttata. 

In yet more advanced conditions of the disease other names are 
employed, all from the external configuration of the patches, none 
having any pathological significance. Thus Psoriasis Nummularis 
is characterized by coin-sized patches ; Psoriasis Circinata or Orbi- 
cularis, by patches where the disease is actively exhibited at the 
periphery of a circle, in the centre of which the scales have dis- 
appeared; Psoriasis Gyrata and Figurata, by coalescence and 
extension of several patches, forming thus fantastic figures covered 
with grayish-white, imbricated scales ; and Psoriasis Diffusa, by 
much more extended and uniform involvement of the skin in large 
areas. 

The greatest variation is exhibited in the progress of the disease, 
and to this point special attention should be directed. Thus, in a 
single individual the eruption may appear upon one or more regions 
of the body in the form of the punctate lesions described above, and 
thereafter regularly progress through the degrees suggested by the 



222 DISEASES OF THE SKIX. 

list of names given above, till the entire surface of the body is com- 
pletely covered (ruin the crown of the head to the sole of the feet. 
This is fortunately rare. More often the eruption tends to remain 
stationary when one or another of the less extensively developed 
phases of the disease lias been displayed. Thus the patches may be 
at no time larger than a silver quarter of a dollar, and though very 
numerous, fail for years to extend beyond such a limit. They may 
even persist for a longer period in even smaller dimensions, or, what 
is perhaps more common, occur in guttate forms upon the chest, and 
in patches as large as the palm over the knee or sacrum. 

The sites of preference of the disease are over the extensor surfaces 
of the extremities, especially about the elbow and knee, where it is 
decidedly most common. After these locations should be named in 
older, the region of the sacrum (where often the largest patch upon 
the body can be discovered), the upper surface of the chest, the scalp, 
the face, the belly, and the genitals; more rarely the hands and feet. 

The disease is essentially chronic in its course, is never contagious, 
and the efflorescence does not usually awaken any subjective sensation. 
Its features are so pronounced in typical cases that its recognition is 
facile, after appreciating the number and distribution cf the patches, 
their clean-cut outline, the unaltered integument between, the lustrous 
and shining scales, and the red border of the skin which may crop 
out from beneath the squamous thatch above, or be completely hidden 
by the latter. Rarely a single isolated patch betrays the existence of 
the disorder. 

When the disease is acutely spreading over the surface it has 
occasionally a different expression. This is often seen in young adults. 
The patches are perhaps as largo as the section of a hen's egg ; dark 
or lurid-red over the whole; covered with a more uniformly con- 
stituted, thin, squamous film, or sheet of semi-transparent delicate 
membrane, through which the red glare of the patch beneath is 
visible. This condition may also be seen in young persons to whom 
arsenic has been administered for the relief of the disease, with the 
production of irritative effects. 

In its indolent moods, the color of the patch varies somewhat with 
the hue of the patient's complexion. Blonde women with flaxen hair 
and clear tint of the integument, often exhibit singularly waxy-whitish 
patches, decidedly differing in color from those occurring upon the 
muddy and greasy integument of certain dark-skinned men. 

The scales are usually abundant, and may adhere with considerable 
firmness to the patch, or, more frequently, be shed freely from the 
surface, in pronounced cases powdering the clothing of the patient or 
the sheets of the bed upon which he reposes at night. 

There is never at any time in the course of the disease, the appear- 
ance of other lesions or their sequelae, such as vesicles, pustules, crusts, 
papules, tubercles, ulcers, or any discharge-feature. The eruption is 
dry from first to last. Exception only may be made in the ease of 
patches occurring where motion of the skin produces fissure, an acci- 
dental and by no means characteristic complication. The same may 



psoriasis. 223 

be said of certain acute symptoms, especially developed in young and 
tender skins, where considerable redness, occasionally with an 
erythematous halo, appears in and about individual patches, with the 
production of itching, heat, burning, pain, or other disagreeable 
sensations. 

The involution of the disease is evident in a gradual cessation of 
the scale-formation and the exhibition of a normal epidermis which 
gradually spreads from the centre, or is at once perceptible over the 
entire surface of the patches. No cicatrization results. 

Upon the scalp, plaques of well-defined contour, covered with thick 
whitish scales, may mat the hairs together, but alopecia almost never 
results. The dry condition of these scales contrasts with the greasi- 
ness of the crusts formed in seborrhcea of the scalp. Often a fillet 
or band of diseased tissue, one or more inches in width, projects be- 
yond the border-line of the scalp and forehead. When the vertex is 
bald from physiological loss of hair, the patch of psoriasis usually 
lingers near the fringe of the hairs left at the sides of the head pro- 
jecting thence to the regions of baldness. On the face as well as 
over the genitals, the lesions are usually both indistinct and small- 
sized, displayed, as regards the former locality, over the cheeks, chin, 
and nose, avoiding the parts near the mucous orifices. When there is 
much vascular congestion, especially of the passive kind, the patches 
assume a violaceous or purplish tint. All forms of lesions are seen 
upon the trunk, especially the dorsum and near the sacrum ; the 
patches, in well-marked cases, encircling the body in ill-defined par- 
allels reaching from the spine forward. The hands, feet, fingers, and 
toes are not often involved, and the palms and soles only so rarely 
as to throw doubt upon a diagnosis based upon the existence of the 
disease solely in these regions. In severe cases, the nails are second- 
arily involved, being thickened, eroded in points, irregularly lamin- 
ated, ridged, and becoming brittle and yellowish-white or dirty- 
whitish* in color. 

The amount of scaling varies greatly in different persons and in the 
same individual ; sometimes the scales are abundant and thickly heaped 
up over even small areas ; sometimes they are sparse over large areas. 
In acute febrile and other intercurrent diseases, the disorder may fade 
or disappear. Where the epidermis is thin, the scaling is less ; there- 
fore, in youth, over flexor surfaces, near the mucous orifices, and on 
the back of the hands, the scaling is less than in advanced years, over 
extensor surfaces, in regions remote from the mucous orifices, and on 
the palms and soles. The disease may be for years limited to two or 
three continuously existing patches, or, what is far more common, 
recur at irregular intervals and under varying circumstances. As a 
rule, it is worse in winter and in cold climates, though patients may 
demonstrate the reverse of this rule. 

The scales may display instead of a lustrous white, a deep yellowish 
shade, and instead of being imbricated, form a thin continuous sheet 
of exfoliated epidermis. When the disease is disappearing, the scales 
fall, leaving a pigmented or slightly discolored patch of integument. 



224 DISEASES OF THE SKIN. 

A rare ultimate termination of the disease is the formation of 
verrucous growths in the psoriatic patches, which later become 
epitheliomatous. 1 At times the eruption is the source of excessive 
annoyance, being the scat of intense pruritic and burning sensations 
of a persistent type. 

There can be no question that intermediate forms between eczema 
and psoriasis occur, in which it is difficult to determine whether 
the two disorders coexist, or the one has assumed the features' 
of the other. In these cases, there is itching' and infiltration of the 
skin, with vesicular and other lesions foreign to psoriasis, and a 
catarrhal discharge. 

Psoriasis is not known to affect the mucous surfaces. The lesions 
of so-called "psoriasis linguae," are those of "leucoplakia bnccalis," 
of "smokers' patches," of syphilitic disease of the mouth, or flat 
epitheliomata. 

Etiology. — The causes of psoriasis arc not known. As no external 
or internal factors can be demonstrated to be effective iu its produc- 
tion, it is safest to conclude that these unrecognized sources of the 
affection are limited to the skin itself. The disease is neither con- 
tagions, hereditary, nor limited to either sex, occupation, or social 
condition. It bears no relation whatever to syphilis, eczema, gout, 
rheumatism, struma, or dyspepsia. It appears iu the feeble and 
delicate as in the most superb specimens of manly vigor and womanly 
beauty. Though not occurring in infancy, it yet usually first appears 
iu early life. Kaposi reports a single case in which the eruption 
appeared in the eighth month, and Eliot, a case of first appearance at 
the eighteenth month of life. Under these circumstances, the question 
arises : Is this affection of the integument, when uncomplicated by 
the disagreeable symptoms named above, a disease or a deformity'.' 
Certainly iu a very large number of individuals, displaying through life 
unchanging patches where the characteristic symptoms are the same 
year after year, the ailment would seem to be more properly' classed 
with the deformities than with the diseases of the skin. In point of 
frequency, the eruption ranks next after eczema. 

Believers in the possibility of the transmission of the disease by 
inheritance are numerous, and some of them careful observers. 
Robinson goes so far as to say, that in the "majority" of all cases 
there is an inherited predisposition to the disease. Others conclude 
it to be an inherited or transmitted form of syphilis, struma, tuber- 
culosis, rheumatism, or gout. Weyl thinks that inheritance may 
possibly be the sole cause. Bazin admits the existence of both an 
herpetic and an arthritic psoriasis. 

Bearing in mind the relative frequency of psoriasis ou the one 
hand, and on the other the strict tests which should be applied in 
order to prove that a disease is actually transmitted by heredity, we 
find that the doctrine of heredity in psoriasis fails of establishment. 
It is putting a low estimate on the actual figures to state positively 

1 See Dr. J. C White's paper, American Journal of the Medical Sciences, 1S85. 



psoriasis. 225 

that there are more than one thousand psoriatic patients in this 
country, no one of whose ancestors, so far as known, ever had 
psoriasis, syphilis, or rheumatism. They furnish too large a body of 
evidence to be either ignored or set aside with a word. Thousands 
of their children are living to-day free for years from any evidences 
of disease. They, too, call for further proof on this point. 

It has long been known that in psoriasic subjects lesions may be 
artificially developed in the lines of mechanical irritation. In this 
way, figures in the shape of anchors, crosses, hearts, etc., have been 
produced on the skin of psoriasic patients, one of which has been 
ingeniously photographed by Dr. Fox, of New York. 1 

The disease is rather more common in male than in female patients, 
and aj>pears to be rare in the negro races. According to Greenough's 
statistics, it represents about two and a half per cent, of all cases of 
cutaneous disease. It has followed vaccination, scarlet fever, and 
other diseases. 

Dr. Gowers alone reports the artificial production of psoriasis by 
the internal administration of the biborate of sodium. Allusion has 
been heretofore made to this circumstance in the chapter on dermatitis 
medicamentosa (q. v.). Further evidence would be required to estab- 
lish the fact that these results differed to any appreciable extent from 
those recognized in any squamous dermatitis produced by an ingested 
drug. 

. Pathology. — The observations of Wertheim, Neumann, Auspitz, 
Kaposi, and Robinson, of New York, are substantially in accord 
respecting the general character of the changes occurring in the course 
of the disease, though they differ upon the question whether it depends 
upon an inflammatory or purely hyperplastic process. So far as this 
problem is illuminated by clinical facts, it would seem clear that both 
views are correct, the disease being at times unquestionably the result 
of a circumscribed inflammation ; at others associated with a simple 
overgrowth of the elements of the epidermis ; and again at times with 
an inflammation which the hyperplasia has awakened. There is 
always abundant development of the epithelia in the rete, and, in 
recently formed patches, distention of the blood- and lymph- vessels in 
the papillary layer of the corium beneath. In older plaques the rete 
either dips downward to an unusual extent between the papillae, or the 
latter push upward in the manner of wart-like prolongations. It is 
reasonable to conclude that at times both hypertrophies concur. The 
corium is thickened later by an increase of its elements which may 
involve its entire width as far as the connective tissue. In the older 
plaques also the connective tissue elements are often separated by a 
slight serous infiltration. Hyper-pigmentation is also noted. The 
external root-sheath of the hairs in direct connection with the rete 
participates in the same process, thus explaining the defluvium capil- 

1 In his admirable Photographic Illustrations of Cutaneous Diseases. New York. 
15 



226 



DISEASES OF THE SKIN. 



litii of certain cases, and the resulting transient or permanent bald- 
ness. The - baceous glands are secondarily involved in the scalp 
only. 

Fro. 38. 







Vertical section of skin from a patch of psoriasis of long standing. 31 P, Malpighian prolongation ; 
C, corium ; L, leucocytes. (After Jamiesox.) 

Lang, 1 of Innsbruck, has attracted notice by his alleged dis- 
covery of certain fungous elements in psoriasis, which he claims to 
be the cause of the disease. These he finds in the whitish pellicle 
beneath the superficial squamous layer, to which Bulkley had 
already called attention. After stripping this pellicle or a part of it 
from the surface, and subjecting it to the action of a five per cent, 
solution of caustic potash, the epithelium becomes translucent, and 
upon and beneath the latter double-contoured and highly refractive 
spores become visible to him. Lang considers this to be a fungus of 
the lowest species, different from any previously recognized upon the 
skin. He terms this " epidermo-phyton." In his treatment of 
psoriasis the author proceeds upon the principles which govern the 
management of the other dermato-mycoses. He considers that the 
value of the remedies hitherto fouud most useful in the disease, such 
as tar, carbolic acid, chrysarobin, and the mercurials, owe their 

i Viert. f. Derm. u. Syph., 1878. 



psoeiasis. 227 

efficacy to their destructive action upon the fungus. He has used 
with advantage a topical application of rufigallic acid in a salve, one 
part in ten. 

Weyl, who believes that psoriasis is due to "an inherited weakness 
of the nervous centres," has seen Lang's "brood-cells," and regards 
them as " myelin-like exudations ; " but this position is disputed by 
both Wolff, 1 and Eklund, 2 who confirm Lang's observations, and 
believe the disease to be of parasitic origin. They explain the arti- 
ficial production of psoriatic patches in the psoriatic skin, by sup- 
posing spores to have been deposited beneath the skin, and not 
previously awakened to activity in the sites of such experiments. 

Lassar 3 has succeeded in producing a disease of the skin in rabbits, 
by rubbing into various portions of their bodies, scales, blood, and 
lymph removed from psoriatic patches in a male patient. The 
disease thus induced is capable of transmission to other animals. 
Campana, Tommasoli, and other Italian observers, have repeated 
these experiments, with the result of reaching the conclusion that 
psoriasis is produced by a parasite as yet unrecognized. 

Diagnosis. — The recognition of a pronounced case of psoriasis is 
made with ease, and often by those unskilled in cutaneous disease. 
As usual, it is the atypical forms of the eruption which occasion 
doubt. It is to be distinguished from 

Eczema. — Eczema and psoriasis differ in a striking manner with 
respect to their sites of predilection, and their extension from such 
sites in progressive cases. Eczema, from the head to the toes, elects 
the anterior surface of the body, the neighborhood of the mucous 
outlets, the flexor faces of the joints and limbs, the crevices, folds, 
pockets, depressions, and protected angles of the skin. Psoriasis 
elects the posterior surfaces of the body, avoids the vicinity of the 
mucous outlets, spreads abundantly over the extensor aspect of the 
joints and extremities, and enjoys the regions of pressure and friction, 
as the skin over the patella and the olecranon process of the ulna. 
Psoriasis, covering the vertex and scalp, lingers at the brow, where 
its scaly thatch stretches from side to side close to the line of the 
hairs, and creeps more indistinctly down the face on either side in 
front of the ear, reluctant to spread over the cheeks, nose, and lips. 
Eczema easily escapes from the scalp to the nose, lips, or chin ; or 
lurks in the folds of the pinna of the ear. Psoriasis will cover the 
back and reach forward in front by almost symmetrically disposed 
parallels in the direction of the ribs, while eczema sweeps between 
and beneath the breasts or around the nipple. Psoriasis will cover 
the belly and spare the navel and pubes where eczema may originate. 
As before stated, the largest patch of psoriasis on the body will often 
be discovered over the sacrum, while eczema creeps upward with a 
diminishing vigor from the anus between the cleft of the nates. 
Psoriasis often spares the hands and feet, which eczema punishes. 

i Viert. f. Derm. u. Syph., 1884. 2 Annal. de Derm, et de Syph., 1885. 

3 Deutscb. Med. Zeit., 1885, No. 93. 



228 DISEASES OF THE SKIN. 

In individual patches eczema will be recognized -by its severe 
itching; the scratching ii excites; the history of moisture, discharge 
and crusting; its ill-defined outline; its asymmetrical disposition, 
except upon the similarly irritated hands and feet; and the fewer, 
more yellowish, smaller, and less lustrous seales which characterize 
its squamous varieties. 

Favus of the scalp might be mistaken for psoriasis of the same 
region, but the occurrence of its sulphur-colored, cup-shaped crusts, 
the existence of the parasite, the lustreless and brittle condition of 
the hairs, and a possible history of contagion, will insure its identifi- 
cation. In psoriasis, too, the hairs are usually firmly attached in 
their follicles, while they are loosened in favus. 

LlCHEN Ruber, though a very much rarer disease than psoriasis, 
must in cases* be carefully recognized as distinct from the latter. In 
it the lesions are papular, distinct, covered by few scales, and these 
yellowish in color, never lustrous. There is always a constitutional 
impairment of health, and, when the whole epidermis begins to break 
up in scales, a condition of well marked marasmus. When scratched, 
the patches of the disease do not bleed. Finally, lichen ruber tends 
to a fatal termination. 

Lupus Erythematosus. — In any doubtful case where cicatricial 
tissue is discovered in the site of a patch where the disease has 
existed, the diagnosis is clear, since psoriasis never leaves a scar. 
Lupus prefers the nose, the cheeks, and other parts of the face, com- 
monly spared by psoriasis unless it be very abundant elsewhere. 
The lupus scales are scanty, firmly adherent, yellowish, and attached 
to the orifices of the ducts of the sebaceous follicles ; those of psoriasis 
are abundant, lustrous, and shed freely from the surface. Lupus is 
never, like psoriasis, a generalized eruption ; and is always much 
more chronic in course. There is a bluish and violaceous tint to the 
reddish patch of lupus erythematosus/ especially as it occurs upon 
the face, while the highly colored patches of psoriasis are rarely 
facial, being more commonly seen on the trunk and extremities, 
wdiile the out-cropping disks on the face are the least colored of any 
on the body. 

Pityriasis Maculata et Circinata. — In this disease the 
patches are more oval than circular, and the scales much finer than 
in psoriasis. It is, moreover, much more rapid in its career and does 
not recur. When the branny scales are removed, the surface beneath 
does not bleed. The centre of the patch is usually tawny or salmon- 
colored. The thoracic surface may also be exclusively involved. 

Pityriasis Rubra. — If psoriasis be in any case generalized, its 
distinction from pityriasis rubra would be difficult, if not impossible, 
on the basis of our present knowledge. Indeed, any such distinction 
would have but little practical value. A few typical isolated 



psoriasis. 229 

patches of a psoriasic character would point to the origin of the dis- 
ease in any doubtful case. 

Seborrhcea. — This disease could only be confounded with psori- 
asis of the scalp. But the last named affection is, in the vast majority 
of cases, exhibited also in patches upon other portions of the body 
where seborrhcea is never seen. Seborrhcea of the scalp also occurs 
in usually diffuse forms, the surface beneath the crusts being rather 
anaemic and pallid in appearance, not bleeding readily, as in psori- 
asis. The crusts, too, iu seborrhcea, are distinctly fatty and greasy 
when rolled between the fingers, and have a dirty-yellowish hue, never 
recognized in the whitish scales of psoriasis. Lastly, seborrhoeic crusts 
may fringe slightly the line of the hairs at the brow, but never form 
a band an inch or more in width, like a frontlet covering the upper 
half of the forehead, a not uncommon development in psoriasis. 

Syphilis. — Psoriasis does in many cases greatly resemble the 
squamous and papulo-squamous syphilides. The necessity for a 
clear recognition of either disease occurring in suggestive patches, is 
often of the highest importance. 

In syphilis the greatest aid will be attained by a history in both 
sexes of infection, adenopathy, and mucous patches ; and of abortions, 
miscarriages, or still-births in women. Psoriasis is a singularly uni- 
form disease ; syphilis decidedly multiform in its manifestations. 
The syphilitic patches are less symmetrical, more elevated at the edge, 
and the scales with which they are covered, fewer, smaller, and dirty- 
whitish, rather than lustrous in color. In syphilis, the eruption is less 
generalized, and shares with the other syphilodermata in the brownish 
and purplish hues of the skin beneath, lacking the vivid redness and 
pinkish-red of many non-syphilitic lesions. The scales of many of 
the syphilides, which resemble psoriasis, partake of the character of 
crusts, being agglutinated by pathological exudations from the patch; 
they are rarely so exclusively squamous as in psoriasis. In syphilis, 
the tendency of the patch is to exhibit an affected surface somewhat 
beyond the line of the scales ; in psoriasis, the scales more frequently 
reach beyond the border of the affected epidermis beneath. The 
squamous syphiloderm of the palms and soles often occurs in these 
localities only. Psoriasis is extremely rare in such situations, and is, 
almost never, limited to that region exclusively. A psoriasiform 
circlet limited to the region of the mouth, nose, or chin, will generally 
prove to be syphilitic. The disease which has for a long time persisted 
in the production of squamous patches can generally be demonstrated 
to be psoriasis ; as syphilis changes its type in the course of months. 

Tinea Circestata. — Here the discovery of the parasite, the his- 
tory of contagion, and the frequent limitation of the disease to a 
single patch (a feature exceedingly rare in psoriasis), will usually 
suffice to establish a diagnosis. In ringworm of the body the scales 
are bran-like, and more abundantly formed at the margin of the 



230 DISEASES OF THE SKIN. 

patch where the fungus is luxuriant ; while in psoriasis, the scaliness 
is usually equally pronounced over the entire area of an invaded 
patch, unless the disease is in process of involution. The occasional 
occurrence of vesicles and vesico -papules at the peripheral border of 
the patch in ringworm, is never observed in psoriasis. Ringworm 
is never generalized symmetrically ; and upon the scalp or beard the 
discovery of brittle 'and broken-off hairs should always suggest 
examination for the parasite. 

Treatment. — As the precise cause of psoriasis is still unknown, all 
treatment fur the relief of the disease must necessarily be limited to 
the removal of its objective features. This treatment may be internal, 
with a view to the indirect action upon the skin, of the drug selected; 
or topical, with a view merely to the reproduction of a sound epi- 
dermis in the patches of disease. 

Arsenic enjoys the highest rank in the internal treatment of psoria- 
sis. What it is capable of accomplishing in other cases, it can with 
best effect accomplish here. Whatever failures must be charged to its 
account in the attempt to relieve other cutaneous eruptions, cannot 
safely be ignored here. 

The facts are these: arsenic administered internally is assuredly 
capable of relieving a certain proportion of cases of psoriasis. Given 
improperly in any case, it may be either powerless or manifestly in- 
jurious. In a certain proportion of patients, most carefully selected 
as fit subjects for its therapeutic action, arsenic will prove utterly 
valueless in the most skilled hands. It cannot be demonstrated to 
possess the power to prevent recurrences of the disease, and yet the 
latter must be recognized as one exceedingly liable to recur. ^ Un- 
fortunately, the proportion of cases in which it will and in which it 
will not, exhibit its happiest effects, is not known. 

The following rules for its administration are to be in general ob- 
served. It should be given with or immediately after the ingestion 
of food, so that it may be commingled with edible substances in the 
stomach. It should be given at first in small doses, which are to be 
cautiously increased. The possibility of the production of toxic 
effects should be remembered, and on the appearance of these the 
remedy is to be given in a smaller dose, and not completely discon- 
tinued unless such a course be imperative. If its administration is 
once determined upon, the arsenic should not be hastily withdrawn 
and another remedy substituted for it, but persistence for months 
should be enforced if no serious objection exist, lest the time be 
wasted which has been already expended in the effort to relieve the 
disease. 

Arsenic is unsuited for all cases of psoriasis occurring with rather 
acute symptoms, such as subjective sensations and unusually vivid 
redness of the patches. It should not be given when the disease is 
in process of evolution, and, therefore, not in psoriasis punctata and 
guttata, unless the lesions have been long limited to patches of the 
sizes to which these names arc given. For the same reasons it is often 
objectionable in the psoriasis of the young, for, though the drug is 
usually rather well tolerated in such periods of life, it is, unfortunately, 



PSORIASIS. 231 

in these also where the disease is most often encountered in its pro- 
gressive stages. 

The remedial effect of arsenic, when such is obtained, seems to de- 
pend upon the impression it exerts upon the rete, and that part of 
it especially which lies in connection with the derma. When the metal 
is injected subcutaneously, its first effects, according to Jamieson and 
Nunn, 1 are indicated by the appearance of a faint narrow band along 
the base of the columnar epithelia immediately next the corium. 
This is due to a softening of the protoplasm which separates the 
epidermal from the dermal elements. Subsequently, the remoter 
epithelia are involved, the protoplasmic threads becoming obscure, the 
characteristic arrangement of the epithelia less evident, and the natural 
features of the rete distorted, so that it remains attached to the derma 
by tags and the prolongations which it sends down to the cutaneous 
glands. Jamieson suggests that arsenic stimulates the epithelia to 
exhaustion, that layer which lies next the bloodvessels containing the 
metal first appreciating its effects. 

The preparation usually employed is Fowler's solution, the most 
soluble of all, whose exhibition should be always begun in doses from 
half a minim (0.033) to three minims (0.20) ; this amount to be 
contained in a solution of fixed and relatively large dose, such as a 
teaspoonful of the infusion of peppermint; the wine of iron ; or 
dilute syrup of gentian or of orange blossoms ; or the compound 
tincture of cardamom with water. When only remedial effects are 
obtained, such as diminution of the scaliness, the dose may be steadily 
continued without change for long periods of time, and usually with 
advantage for some time after the symptoms of the disease have 
entirely disappeared. When, without the production of toxic effects, 
the eruption seems quite unaffected by the treatment, the arsenic may 
be, very carefully and always under the direction of the physician 
only, pushed till twenty and even thirty drops of the Fowler's solu- 
tion [the latter equivalent to one-third of a grain (0.22) of arsenic] are 
administered at a dose. 

The constitution of the Asiatic pill has been given in the chapter 
on general therapeutics. The pill is less likely to be as well tolerated 
by the stomach as Fowler's solution, but cases are on record in which 
the psoriasis which proved rebellious under the administration of the 
liquor arsenicalis, Donovan's solution, and other internal remedies, 
yielded to the influence of the arsenious acid in pilular form. Hebra 
has given two thousand Asiatic pills to a single patient before the 
disease disappeared; and in no instance has he seen any ill effects 
produced. 

With regard to the vulgar opinion respecting the arsenic habit which 
a long familiarity with this dosage has been supposed to beget, the 
author considers it a curious circumstance that he has never yet 
encountered such an instance in a psoriasic subject who was consum- 
ing arsenic. Patients who for several consecutive years have, without 

1 See the paper by the former on the Histology of Psoriasis, Edinburgh Medical Journal, January, 
1879, p. 627. 



232 DISEASES OF THE SKIN. 

interruption, pursued an arsenical course, thus barely succeeding in 
keeping their cutaneous ailment out of sight, will in many cases affirm 
that, apart from any trifling and accidental toxic symptoms, and 
those evident in the course of the eruption, they would not be sensible 
of the fact that they had taken the drug. 

With an enlarging experience, one views with greater distrust each 
year the benefits to be derived from arsenic in any untried case of 
psoriasis. The great possibilities of its failure, of the repeated re- 
currence of the eruption, of the necessity of continuing the medication 
for one or two years, and even after that period of time, of even then 
witnessing a generalized development of the disease to an extent 
quite equal to that exhibited at the outset, all these considerations 
should certainly have some weight in the mind of an ordinarily 
prudent man. Is the ultimate result in such cases worth the cost by 
which it is obtained ? In such cases certainly it would seem not. In 
the others, where, under a judiciously directed arsenical course, the 
eruption slowly disappears and fails to recur, the value of the treat- 
ment is incontestable. As before stated, the proportion in which these 
two classes of cases are related, is not known. The patients in the 
last-named category, in all probability, decidedly outnumber the 
others. 

The course which, under the circumstances, seems preferable, is this : 
Instead of resorting first to the arsenical dose and afterward to other 
measures, the order should be reversed. That psoriasis which fails to 
respond to other treatment, may be finally subjected to the influence 
of arsenic. He who, having vainly tried other approved measures, 
essays at last the virtues of this medicament, ought certainly to ex- 
hibit no impatience while testing his case with it. He should be 
willing to try it fully and fairly, and be of all men least ready to 
exchange it for a less valuable substitute. No reference is here made 
to the effect of conjoined internal medication with arsenic and external 
treatment by topical applications However desirable it may be, in 
the management of any individual case, to arrive at the desired end 
by the speediest method, it is evidently needful, in order to assign to 
arsenic its exact therapeutical value, to understand what it can accom- 
plish unaided by topical measures. 

As to the other remedies employed internally for the relief of the 
malady, a very fair estimate of their value can be made by remember- 
ing that arsenic is superior to them all. If arsenic fails so frequently, 
what remains to be said of the other articles in the list ? Phosphorus, 
tar, copaiba, eantharides, colchicum, and pilocarpine, have at times a 
feeble or transitory influence over the patches of the eruption, but 
their employment will disappoint far more often than satisfy. Iron, 
quinine, cod-liver oil, and the salts of the alkalies, will fill important 
indications in the treatment of certain classes of patients, but these 
are in the minority, as the eruption is often seen in perfectly vigorous 
and otherwise healthy subjects. 

After the use of any one of these remedies, it is rare to recognize any 



psoriasis. 233 

decided effect upon the cutaneous symptoms, even when patients in 
whose case they were indicated, improve under their use. 

The same in general may be said of the use of dietary articles in 
psoriasis. As no ingesta save the substances already named are re- 
cognized as influencing the eruption to any perceptible degree, the 
diet suitable for a patient may be in brief described as that which is 
both wholesome and nutritious. 

Most authors agree upon the value of a greatly restricted diet. 
Acids, alcohol, and fatty substances should be excluded. Meat 
should be sparingly supplied; cooked vegetables and fruits may be 
freely eaten. Coffee, tea, and tobacco should in general be interdicted. 

Passavant, of Frankfort, on the other hand, claims to have cured 
himself and others, by an exclusive diet of meat. 

The arseniate of sodium in pill form and arseuiate of iron have been 
recommended by Biell. Lipp has injected arsenious acid subcuta- 
neously. Robinson advises the liquor potassa?, the citrate or acetate 
of potassium, or the bicarbonate of sodium in plethoric and rheumatic 
patients. In the gouty state with excess of urates in the urine, he 
advises : 

R . Potass, acetat. . |j ; 32 

Spts. asther. nit. f§ss; 16 

Vin. colchici f ^ij ; 8 

Syr. aurantii f §jss ; 48 M. 

A dessertspoonful three times daily in water after meals. 

The influence of climate in inveterate psoriasis should never be 
ignored. It has been already stated that many patients who suffer 
from repeated relapses of the disease are worse in winter, and either 
better or entirely free from the eruption in summer. For the same 
reason, in a mild climate, where the temperature is uniformly regis- 
tered at or near a point of maximum comfort for the skin, the disease 
will be both infrequent and less severe. 

McCall Anderson believes that sea-air and sea -water are generally 
prejudicial to psoriasic patients, but the statement is disproved in the 
cases of hundreds who have removed from an interior climate to the 
sea-shore, solely with a view to the benefit to be thus received. 

The external or local treatment of psoriasis requires patience, care, 
and a certain degree of skill. Properly conducted, its results are 
reasonably satisfactory in a large majority of cases. 

The first indication to be met is the complete removal of the 
epidermic scales from the patches, and this is accomplished in various 
ways. It is preferable to secure first their maceration in some fatty 
substance, such as one of the oils, or glycerine, or vaseline, after 
which they may be washed off by the aid of soap and water, in a 
general bath if the eruption be extensive. If it be localized, these 
oily or fatty substances may be spread upon pieces of lint or cotton, 
and thus retained by a bandage in contact with the skin. The scales 
may also be speedily removed with the dermal curette, if they occur 
in few patches, or if the latter are to be found in totality or part 



234 DISEASES OF THE SKIN. 

upon some portion of the body where the disfigurement demands 
special attention, as upon the forehead and cheeks. The squamous 
masses arc also removable by water alone, as after maceration of the 
skin in a bath, or after a profuse diaphoresis, or even moderate 
exudation of sweat, if evaporation of the latter be prevented by 
covering the affected part with oiled silk or rubber cloth. Usually 
there is do difficulty in removing these scales, patients often declaring 
to their physicians that they can themselves cleanse the surface, if 
they can be shown how to prevent the recurrence of the desquamation. 

Baths play an important part in the subsequent treatment of the 
disease. They may be employed, as by Hebra, so that the patient 
remains in the water for from four to eight hours in the day; or be 
medicated by the addition of sulphur, tar, or other substances, so as 
to combine a medicative with a macerative effect. In private prac- 
tice, these baths are much less available than in hospitals. When 
the eruption is generalized and an excessive macerative effect is 
desired, the rubber clothing answers a better purpose. In such cases 
an undershirt and drawers may be worn, made of soft rubber cloth, 
of the size of the undergarments usually worn by the patient, the 
latter wearing these for several hours of the day. The sweating is 
often profuse and debilitating to such an extent that the psoriasic 
skin will rarely tolerate the treatment for an entire day, or for even 
that part of it in which active labor is performed. By this means 
alone, it will at times be found possible to secure complete disap- 
pearance of the patches. 

In other more obstinate cases, or in those where for any reason 
such treatment is indicated, as upon the scalp and face, the sapo 
viridis may be employed with advantage in the soap and water treat- 
ment. The spiritus saponis kalinus [two ounces (60.) of the soap to 
one (30.) of alcohol] may be briskly rubbed over the patches by the 
aid of a piece of flannel or sponge, and then immediately washed off 
with the oil and scales in a surplus of hot water, or be left for a time 
in contact with the part. Hebra and Kaposi make use of a species 
of soap paste, made by rubbing into each patch a small quantity of 
the green soap to which a little water is added till the proper con- 
sistency is obtained. These inunctions are repeated twice daily for 
six days. The epidermis becomes then brownish-colored, and in 
three or four days afterward exfoliates in lamellae. Then a general 
bath cleanses the surface. In the French hospitals, a someMhat 
speedier method is pursued. On the evening of the first day, the 
patient is anointed with the green soap which he retains upon the 
skin during the night. In the morning he takes an alkaline bath, and 
immediately after is thoroughly anointed with lard. This is repeated 
on the second and third days, after which the patient is usually 
ready for any topical medication of the diseased parts. 

For the yet more obstinate cases in which the exfoliation of the 
epidermis is not readily induced, still more energetic measures have 
been adopted, such as the local use of salicylic acid in alcohol, one 
drachm (4.) to four ounces (128.), caustic acids and alkalies, scrub- 



psoriasis. 235 

Hug the patches with nail-brushes, floor-brushes, etc., and the use of 
clean, white sand. 

Once ready for topical medication, the patches may first be sub- 
jected to the local action of tar, a remedy which has enjoyed the 
highest reputation for the relief of the disease. It will, however, 
accomplish the result desired, only when applied so that it is well 
tolerated by the skin. In very young patients, as also in those 
whose skins are tender and irritable, or who are suffering from any 
of the acute phases of the disease, it may prove decidedly injurious 
by aggravating the latter. The rule should be, always to employ it 
at first tentatively over a relatively small portion of the surface, 
upon which the medicament should remain for several hours, as tar 
will not in all cases promptly produce its injurious effects. These 
are, subjectively, a sense of heat and pain ; and, objectively, heat to 
the touch, redness, and tumefaction of the part. Often black puncta 
are visible when the tar is lodged in the orifices of the cutaneous 
follicles, simulating thus, the "black head" of the comedo, a con- 
dition termed by Hebra, "tar-acne." 

Pix liquida, the oil of cade, or preferably the oleum rusci may be 
•employed, in the form of a salve, a drachm (4.) of either to the 
ounce (32.) of lard or other fatty basis (lanoline, vaseline, etc.). 
A thin stratum of such ointment may be, several times in the day 
or merely at night, painted over, or well rubbed into a patch denuded 
of scales. In Vienna, a still more energetic effect is secured by 
using the soft soap freely over the patches while the patient is in the 
bath, then anointing him with tar, and finally returning him to the 
bath where he remains for from four to six hours. For localized 
eruptions, the green soap in combination with tar and alcohol, serves 
an exceedingly useful purpose, either in the proportion of equal parts 
of the three ingredients, or by combining them in other proportions, 
as, for example : 

R. 



Saponis viridis 


Siv; 


130 


01. rusci | 
Glycerin, j 


aa I) ; 


30 


01. rosmarin. 


3jss ; 


7 


Spts. vin. rectif. 


Oss;' 


500 


For external use. 







M. 

Other combinations of service are Bulkley's " liquor picis alka- 
linus," the formula for which is given in the chapter on eczema ; and 
Wilkinson's salve, as modified by Hebra, the latter combining the 
remedial effects of sulphur, tar, and soap, as follows : 

R. Sulphur, sublimat. { -- - ir 

01. rusci [crud.vel. rectif.] j aa 3SS ' lb 

Saponis viridis ) -- z , . „ fl 

Adipis j aa ^' S0 

Cret. praeparat. 9yss; 3 5 M. 

Sig. Wilkinson's salve modified. 

. Where the sensitiveness of the skin to the action of the tar has 
not been tested, or when the skin is particularly tender, a small 



286 DISEASES OF THE SKIN. 

quantity of the Wilkinson salve may be added to any simple oint- 
ment, or Spender's ointment of tar (see the chapter on General 
Therapeutics) may be substituted for it; afterward a drachm (4.) 
of the oil of tar, or oleum nisei, to the ounce (32.) of oil of almonds 
or of alcohol, may be employed. 

When toleration is established, the tar may be rubbed over the 
patches in a pure state with a stiff brush, a procedure preferred in 
some parts of Germany, after which the patient either remains for 
some hours in bed, or is powdered with soapstone and bandaged with 
flannel, so that when the clothing is replaced it may not adhere to 
the tar. Naphthalan, ichthyol, and carbolic acid operate in psoriasis 
in the same way as the tars, but are decidedly inferior to it. 

Absorption of any tarry compound applied externally may result 
in general toxic symptoms, including fever, vomiting, diarrhoea, 
strangury, and elimination of the toxic agent in secretions which are 
blackened by its presence. These symptoms are usually relieved in 
from twenty-four to forty-eight hours after the discontinuance of 
the drug. 

Kaposi 1 was first to employ beta naphthol, the formula of which 
is C 1() H 8 in psoriasis (as also in eczema). It may be applied in 
alcoholic solution. Under the employment of a fifteen per cent, 
ointment, the author reported speedy disappearance of psoriasic 
patches. It did not stain the skin, hair, or nails. 

Balmanno Squire, 2 however, reports that the naphthol was, in 
certain experiments conducted by himself, without appreciable effect 
when used in the strength of from ten to twelve per cent., and that, 
when he increased the quantity of the agent till the ointment was 
applied in the strength of twenty-five and even fifty per cent., there 
was the production of merely irritative effects. 

By many practitioners, chrysarobin or chrysophanic acid is placed 
above all the tars in the local management of psoriasis. It is a 
crystalline powder of the color of old gold, insoluble in water, but 
readily dissolved in hot alcohol, acetic acid, benzol, vaseline, and hot 
fat. It is derived from the "goa-powder" of the East Indies, or the 
"araroba powder'' of Brazil, whose employment in psoriasis was first 
recommended by Mr. B. Squire, of London, Eng., in 1878. 

In 1880 the author collected specimens of this powder from the 
leading chemists of Boston, New York, Philadelphia, and Chicago; 
and finding these to vary greatly, both as regards the color of the 
preparation and the therapeutical effects induced, he has since largely 
employed the Brazilian araroba em po s with better results. 

The drug is best applied in the form of an ointment, varying in 
strength from half a scruple (0.666) to a scruple (1.333) to the ounce 
(32.) of vaseline or cerate. It is occasionally used in greater strength, 
but, with pure specimens, it is liable in larger proportions to produce 
disagreeable effects. These are declared in a hot, itching, swollen,. 

1 Wien. Med. Wochensch., May 28, June i and 11, 1S81. 
= Brit. Med. Journ., Jan. 14, 1882. 
Ihie article was obtained frum Messrs. Silva, Limaos & Co., of Babia, Brazil. 



psoriasis. 237 

irritable, and erythematous skin, stretching from the surface of appli- 
cation, with tolerable uniformity, in every direction. It is, even in 
the strength named above, necessary to begin its use with caution, 
testing it by application first to a limited area of integument. These 
excessive effects usually subside in a few days. An ignorant woman 
to whom a chrysarobin ointment was given in 1879, with directions 
to test it. carefully at first by application over the elbows of her 
daughter, stripped the latter before an open fire, and rubbed the oint- 
ment over the entire surface for the space of half an hour. The 
result was an intense erythema lasting for six clays with considerable 
■distress, and the complete disappearance of the psoriasis which did 
not fail to reappear in eight months. 

When the drug produces its most brilliant effects, the psoriasic 
patch, previously denuded of its scales, assumes a whitish and normal 
aspect, contrasting thus somewhat remarkably with the chocolate to 
brownish-black discoloration of the normal skin at the periphery. 
This coloration, when produced either by the ointment directly or by 
a frequent transfer of its ingredients to other parts by the medium 
of the clothing and hands, involves also the nails, hairs, and under- 
linen of the psoriasic patient. Its employment upon the face and 
scalp is thus largely interdicted. The staining of the skin and its 
appendages disappears entirely in time, but always slowly. 

An improved plan of using chrysarobin externally has been sug- 
gested by Fox, of New York. 1 

A soft paste is made by rubbing the chrysarobin with a sufficient 
quantity of water, and smeared upon the psoriasic patches, the scales 
of which have been previously removed by one or more hot baths, 
with soap friction. As soon as the paste has dried, which it does in 
one or two minutes, a layer of collodion should be allowed to flow 
over each patch, and to harden into a protective coating. This will 
remain in place for several clays, or longer, according to the location 
of the patches ; and when it falls, or is washed off, the application of 
the powder and the collodion should be repeated. By this procedure, 
the chrysarobin in full strength is kept in contact with the affected 
skin, and prevented from exciting undue inflammation of surrounding 
parts, or staining the clothing. A mixture of the powder and the 
collodion may be used, but it is less efficacious. A film of collodion 
doubtless interferes with the action of the acid upon the skin. A 
somewhat similar plan consists in the use of gutta-percha tissue to 
retain a strong chrysarobin ointment in contact with psoriasic patches. 
The edges of this tissue will adhere tightly to the skin if a small 
camel's-hair brush, clipped in chloroform, be passed rapidly beneath 
them. 

More recently, following Auspitz's plan, this same author has 
combined these articles in a convenient form, by adding ten parts of 
chrysarobin and ten of salicylic acid to fifteen of sulphuric ether 

i The Medical News, March 18, 1882, p. 289. 



238 DISEASES OF THE SKIN. 

and one hundred of flexile collodion. This rapidly dries over the 
psoriasic patch, whirr its specific effects are produced. 

Pyrogallic acid, first suggested as a remedy for psoriasis byJarisch, 
is inferior to chrysarobin. The fact that several deaths have now 
beeo reported as consequent upon its use deters many from making 
trial of it in a painless and merely disfiguring disease. It is used in 
a tin per cent, vaseline ointment; is effective, though less rapid in its 
effect than chrysarobin; is cheaper; is odorless and painless; and 
discolors to a less extent the sound skin. Both remedies are capable 
of being absorbed from the surface, and of producing constitutional 
symptoms, pyrexia, strangury, ami blackish evacuations. But in the 
case ->f pyrogallic acid only, so far as is known, have these symptoms 
resulted fatally. 

Crocker, of London, similarly uses thymol in ointment, half a 
scruple to half a drachm (0.666-2.) to the ounce (32.); and Wil- 
liamson advises turpentine two drachms (8.) to the ounce (32.) of 
olive oil, with the odor corrected by the oil of lemon. Charteris 
treated thus a single limb of a psoriasic patient, which was subse- 
quently wrapped in wool, with the curious result of relieving the 
psoriasis of the other limb, possibly in consequence of the absorption 
of the remedy. The danger of strangury in such cases must not be 
overlooked. 

The nitrate, as well as the iodides and oxides, of mercury is applied 
by many practitioners in the form of ointment to patches of psori- 
asis, usually few in number, and limited in extent. The action of 
these agents is, however, inferior to those already named, and the 
range of their availability being quite limited, they should be 
esteemed lightly in the local treatment of the disease. 

The local treatment of psoriasis of the scalp and face by many of 
the articles named above is often forbidden by reason of their dis- 
agreeable odor or too energetic action, or by the staining which they 
produce. 

There is no better substitute for them all in these regions than the 
ammonio-chloride of mercury in ointment, from ten to thirty grains 
(0.66-2.) to the ounce (32.). In the same way, the tincture of 
benzoin may be employed, half a drachm (2.) to the ounce (32.) 
of salve. 

PrtKjnoHis. — The permanent relief of psoriasis is not insured by 
any treatment of a grave case, though hundreds of cases are perma- 
nently relieved by even the simplest treatment. The disease often 
recurs, and may do so repeatedly for the greater part of a life. Per- 
manent relief, therefore, should never be either predicted or promised 
in any case. Once relieved, it should be the aim of the practitioner 
to guard against all possible recurrences. After relief of any obsti- 
nate or recurrent attack, as also in all inveterate cases, the prognosis 
is greatly improved by removal to a climate suitable for the psoriasic 
patient. 



PITYRIASIS MACULA.TA ET CIRCINATA. 239 



Pityriasis Maculata et Circinata. 

Pityriasis Maculata et Circinata is a mild febrile disorder of specific character 
and determinate course, in which appears a cutaneous exanthem in the 
form of multiple, circumscribed, superficial, roundish or oval-shaped, 
yellowish and reddish patches, covered with fine scales, and seated for the 
most part on the trunk. 

This disorder, also termed Pityriasis Rosea and Pityriasis Circinata, 
has been recognized and carefully described by Gibert, Bazin, Horand, 
and Duhring. 

It is a rare disorder, the expert seeing not more than from ten to a 
score of cases annually. It is also non-contagious and benign in its 
course, lasting from a few weeks to three months. 

Symptoms. — The subjects are children, or more commonly young 
adults, but the author has seen it in middle life in both sexes. The 
outbreak of the disease may be preceded for a variable time by 
languor, lassitude, inappetence, or a feeling of chilliness. Occasion- 
ally the first noticeable symptom is in the occurrence of mild fever, 
the temperature rarely rising above 102° F. 

The eruption often escapes recognition for a time after its appear- 
ance on account of its sparseness, or the trifling degree of pruritus it 
arouses. When fully developed, it is characterized by the conspicuous 
appearance over large surfaces of the trunk, especially the integu- 
ment covering the clavicles, ribs, and scapulae, of numerous pin-head 
to small coin-sized, circumscribed, roundish or oval-shaped, slightly 
elevated, macular or maculo-papular lesions. These may be discrete,, 
closely set together, or confluent, and instead of being elevated may 
be either on a level with the general surface, or even slightly de- 
pressed, with an annular border. They are dry, covered with fur- 
furaceous scales, and vary in color from a yellow or tawny shade to 
a deep red. The infiltration is slight, and the patch is superficially 
situated. 

The oval contour is that more often recognized as characteristic of 
a well developed lesion, its long axis usually at right angles to the 
vertical axis of the body, and the terminal extremities of the oval 
slightly frayed by the irregularity with which the fine branny scales 
are here disposed. The tawny, salmon-shaded hue of such patches 
is then highly characteristic of the disease, the patch slightly enlarging 
by peripheral extension, and leaving a relatively clear centre. The 
scales have often a silvery-grayish hue. The eruption may be toler- 
ably well generalized, but the face and other exposed parts of the 
body usually escape, though the scalp may be involved. In the 
latter event the hairs are unaffected. 

Etiology and Pathology. — The causes of this disease are obscure. 
According to Bazin, it occurs in lymphatic and scrofulous patients 
chiefly. 

The most of the cases coming under the author's observation were 
of patients having light hair and delicate skins, who had been 



240 DISEASES OF THE SKIN. 

enfeebled by great physical fatigue or overtaxation in school. Profuse 
perspiration has been assigned as a cause by Horand. Vidal 1 recog- 
nized in the upper portions of the epidermis minute spores in heaps, 
chains, and circles, called the microsporon dispar (s. anomseon.) which 
have unquestionably been seen in other scaling diseases of the skin. 

Diagnosis. — The disease is to be differentiated from ringworm of 
the body by the absence of vesicles, the tendency to symmetry of dis- 
tribution of the lesions, their multiplicity, the characteristic yellowish 
centre of the oval rather than circular patch, and the constitutional 
symptoms. Psoriasis differs greatly in the color, quantity, and char- 
acter of the scales present, and in the contour of the patch. In the 
scaling syphilodermata, the region of the body involved, the presence 
of plantar and palmar lesions, the constitutional symptoms and history, 
and the color of the patch, which is usually of a deeper and dirtier 
red than in the disease under consideration, will point to the diagnosis. 
In the macular syphiloderm ('"syphilitic roseola") the closer prox- 
imity of the lesions will point at once to the difference, since the 
patches of pityriasis maculata et circinata are, as a rule, far more 
widely separated. The greasiness of seborrheic scales and the pallid 
hue of the integument beneath, when the former are removed, differ 
from the congested skin beneath the dry scale in the form of pityriasis. 

The treatment is expectant. Quinine, the sodic salicylate, and, 
later, the ferruginous tonics are indicated in most cases. Finally, 
tepid bathing in the alkaline or bran bath is usually found grateful. 
This is to be followed by the application of a dusting powder. 

Dermatitis Exfoliativa. 

Exfoliative Dermatitis is a more or less generalized, cutaneous disorder in 
which, either in circumscribed patches or over the entire surface of the 
body, the skin is reddened and covered with scales which are freely exfol- 
iated from the surface. The disease may be accompanied by febrile and 
other general signs of systemic disturbance. 

Some confusion, both as to the names of diseases and as to the dis- 
eases themselves, has existed in connection with the subject of all 
generalized exfoliative cutaneous disorders. More investigation is 
needed before definite limits can be established for several of the 
disorders to which authors refer under these titles. By some, the 
term dermatitis exfoliativa is held to be synonymous with pityriasis 
rubra, the disease next to be considered. In these pages, pityriasis 
rubra is, for the present at least, distinguished as a distinct disease, 
and dermatitis exfoliativa is made to include the exfoliative and exu- 
dative disorders of the skin not properly considered in any other 
connection. 

Classing these latter together, as for the most part of acute type, and 
distinguishing them from the chronic form of dermatitis exfoliativa 

1 See a communication by the author in the British Medical Journal, April 2, 1S87, on the distinction 
between seborrhcea, pityriasis maculata et circinata, and lichen annulatus serpiginosus (Wilson). 



DERMATITIS EXFOLIATIVA. 241 

represented by pityriasis rubra, it may be said of them all that they 
often present features of wide diversity. At one time the exfolia- 
tive dermatitis begins and ends in a single patient as a well-defined, 
distinct, and specific disease of mild symptoms, definite career, and 
benign type. In another case, it occurs as a sudden or gradual 
change in a preexisting disorder, such as an eczema or a psoriasis 
(Gamberini) Again, beginning in one or another of the simpler 
forms described above, it may become chronic, and, in its symptoms 
and course, be indistinguishable from a pityriasis rubra. 

It may be ushered in with mild febrile symptoms, which may have 
been preceded or not by malaise, languor, or a variable period in 
which the general health has been impaired. Often, however, all 
prodromata are absent. 

The eruptive symptoms are a more or less shining and vivid red- 
ness of the skin in one or several plaques which become in the course 
of a week the seat of numerous fine bran-like scales. Any region of 
the body may be affected, though the articular folds of the skin, 
genital region, head, and trunk, are often the seat of the disease, 
which may involve consecutively one part after another till, in a week 
or a fortnight, the whole surface is invaded. It may be limited to 
one region, or, yet again, several distinct regions may be simultane- 
ously involved., as the head and lower limbs, or the thorax and 
external genitals. The hands and feet are usually the last to be 
invaded. The eruption may appear in reddish patches of well- 
defined or very indeterminate outline. The skin affected may be 
slightly, or apparently not at all, infiltrated and raised. The itching 
may be slight or severe. The redness displayed in the skin which 
is the seat of the scaling, may be of the brightest crimson, " erysipe- 
latous," violaceous, or purplish shade, or with a faint suggestion of 
yellowness. The scales are usually formed in the greatest abundance 
and are commonly seen loosely covering the reddish integument upon 
which they rest, though they are also shed in the greatest profusion 
when the surface is lightly swept with the hand. They are always 
whitish, minute, and bran-like, never in the so-called pastrv-crust 
condition of the scales in pemphigus foliaceus. 

In well-marked cases, the features may be slightly disfigured by 
tumefaction of the lips, swelling of the ears, and puffiness of the lids. 
In all cases, the skin is dry and never moistened by a pathological 
discharge. The scales shed in such abundance are always white, 
imbricated, and silvery in hue. They are usually larger and coarser 
upon the lower limbs than over the neck, face, or chest. 

In the course of the disorder, the hairs may fall ; and, in some 
cases, the resulting alopecia is general. When the nails also are lost, 
there is rarely any special preexisting onychia to be noted. The 
mucous surfaces of the eyes, nose, mouth, and throat, may participate 
in the general disorder and become the seat of inflammatory and, in 
rare cases, even pseudo-membranous and exulcerative processes. 

The itching may be entirely absent ; when present and in severity, 
it is relieved even before the complete restoration of the integrity of 

IB 



242 DISEASES OF THE SKIN. 

the skin. It is apt to recur with each relapse, at which time also the 
fever is usually relighted. 

In most cases the disease is terminated in the course of two or 
three months, after which convalescence from the emaciation and 
possible complications (furunculosis, abscesses, etc.), may require an 
equal length of time. Pigmentation is always left for some time 
after the restoration of the health of the skin. 

Pathology. — Brocq 1 has made a specially careful study of this dis- 
order, and his results are more or less confirmed by Vidal and 
Baxter. These observers recognized an infiltration of the papillary 
layer of the corium with embryonic cells, dilatation of the papillary 
and sub-papillary vessels, disappearance of the stratum grauulosum 
and stratum lucidum of the epidermis, and appearance of nuclei in 
the cells of the stratum corneum. According to Quinquaud, 2 a dif- 
fuse myelitis and parenchymatous neuritis of cutaneous nerves may 
be responsible for all these changes. 

Etiology. — According to Brocq, the disease affects patients who have 
not previously suffered from any cutaneous malady. The disease is 
rare ; and is said to occur more often in adult male subjects. 

Diagnosis. — The disease is to be distinguished from pityriasis 
rubra by the variety of its symptoms and course ; from pemphigus 
foliaceus by the absence of bullae and grave systemic trouble ; and 
from scarlet fever, by the absence of sore throat and its much more 
tardy evolution. Though, in general, a disease having a cyclical 
career and special characteristics, it may at times be lighted into 
activity by a diffuse psoriasis of acute type, or a squamous eczema 
becoming generalized. In such cases the diagnosis is qualified by 
the preexisting disorder. 

Treatment. — The disease is unquestionably most relieved by any 
article which induces profuse sweating; and, hence, both jaboraudi 
and pilocarpine have been employed in it with even brilliant success. 
Quiniue, the sodic salicylate, and the mineral acids are often indicated. 
The strength of the sufferer is always to be supported by appropriate 
measures. Hebra's diachylon ointment, one part to four of vaseline, 
with from five to ten grains (0.33-0.66) of salicylic acid to the ounce 
(32.) of the whole, is usually most grateful to the skin. One of the 
combinations of lime-water, olive oil, and the oxide of zinc, described 
in the treatment of eczema may, however, be well employed as a sub- 
stitute for it. 

Prognosis. — The disorder may prove fatal in exceptional cases. 
Generally, however, recovery may be expected. Often the conval- 
escence is tedious, protracted, aud complicated by the occurrence of 
furuncles and cutaneous abscesses. 

Dermatitis Exfoliativa Infantum. — Under this title V. 
Rittershain 3 and others have described an exfoliating non-contagious 
disease of the skin in infants from six days to five weeks old, the 

l Arch. Rc-n. do Mi'-d., 1884. 2 Bulletin de la Societe Anatom., 1879. 

3 Ctralztg. f. Kinderheilk., 1878, Bd ii. 



PITYRIASIS KUBRA. 243 

disorder running from seven to ten days. It is characterized by 
dryness of the skin, from which branny scales are exfoliated, leaving 
a peculiarly dry, reddish, and fissured integument beneath. The 
angles of the mouth and mucous outlets generally are specially 
involved. Often buccal lesions are present. The face and limbs are 
the seat of the chief features of the disease. The malady occurs 
more often in boys than in girls. In severe cases crusts form where 
the rhagades exist, and there is considerable pain and constitutional 
disturbance. Occasionally the skin is attacked by furunculosis after 
the disease has existed for a week. 

Pityriasis Rubra. 

Gr. irirvpa, bran. 

Pityriasis Rubra is a rare, chronic, and usually grave inflammatory cutaneous 
disease; as a rule, involving the entire surface of the body, in which the 
skin is deeply reddened and exfoliates lamellae of scales in large quantities. 

This disease is characterized throughout its course by a superficial 
hypersemia and inflammation of the skin, declared by a diffuse red- 
ness of a vivid or lurid tint, and an abundance of small or large, 
lamellated, bran-like scales, which are continuously exfoliated from 
the epidermis throughout the course of the disease. Patients rarely 
present themselves for observation till a considerable portion of the 
surface is involved ; but Kaposi states that in two cases observed by 
him the disease was first noticed in the neighborhood of the articula- 
tions. There are never at any time other lesions of the skin, betrayed 
in vesiculation, pustulation, moisture, or crusting. The palmar and 
plantar surfaces are usually less distinctly reddened than the face and 
extremities, having at times even a pallid hue ; but they are always 
covered with a distinctly scaling epidermis. 

Under pressure with the finger, the redness subsides or assumes a 
yellowish shade, while, as a rule, when the integument is gathered 
up between the finger and thumb, no thickening and infiltration can 
be recognized. Exceptions to this have been, however, noticed by 
several observers, the author among the number, in an interesting 
case made the subject of a clinical lecture. 1 The temperature of the 
skin is slightly increased. The exfoliatiou is, as the disease progresses, 
one of the most striking of its characteristics, the scales accumulating 
in large quantities about the coverings of the body of the unfortunate 
patient, who is engaged, as a French writer has it, in the labor of 
stripping himself involuntarily of his epidermis. 

The disease persists for months and years, always more severe in 
expression as it advances, the papery scales being shed more abun- 
dantly, and in larger flakes, leaving beneath them a smooth, shining, 
occasionally purplish or even cyanotic skin. In the cases observed by 
Jamieson, 2 of Edinburgh, and the author, the skin was so dark-hued 

1 Pityriasis Rubra : Chicago Med. Journ. and Exam., Feb. 1881. 
" Edinburgh Med. Journ., April, 1880, p. 879. 



L'44 diseases of the skin. 

;,, to suggest the color of the mulatto. Gradually the patient is 
conscious of an increasing sense of chilliness, as it' deprived of suf- 
ficient bodily covering. The itching may be absent, moderate, or 
severe. Later, the integument seems to retract, as if insufficient to 
encompass the body, and becomes subject to fissure from extension 
and contact, while the lower extremities may even be ^edematous. 
This retraction may be so marked that ectropion of the lid may 
ensue, and wide opening of the mouth, become difficult. The hairs 
and nails lose their lustre, and become friable, often falling, though 
at times escaping altogether. 

The influence of this gigantic, epidermal catarrh, involving, as it 
does finally, every portion of the surface, does not fail, toward the end, 
to be perceived by the vital forces. Alternating chills and febrile 
processes, pneumonias of a low grade, colliquative diarrhoea, tuber- 
culoses, subcutaneous abscesses, bed-sores, and even gangreue of the 
skin may close the scene. 

Hebra and Kaposi have together had under observation "about 
fifteen" patients affected with pityriasis rubra, who, with a single 
exception, died from its effects. It will be seen thus that the disease 
is exceedingly rare. A few interesting cases have been reported by 
English authors. Among Americans, Duhring, George H. Fox, of 
Xew York, and the author, have published reports of cases. The 
disease is oue of early or middle life, and preeminently of the male sex. 

Etiology. — The causes of the disease are absolutely unknown. 
It will be seen that the small number of cases which have been 
recognized, furnish but an insignificant field for the study of the 
malady. It is interesting, however, to note in this connection, that 
the constitutional symptoms of each case seem to have been induced 
by the disease of the skin, and not the latter by any internal derange- 
ment of which the symptoms are made manifest. For not only do 
these visceral troubles occur chiefly at a late period of the malady, 
when common observation suffices to show that the cutaneous mis- 
chief alone is sufficiently extensive to iuduce them, but it is also clear, 
from the wide range of these disorders (bowels, lungs, etc.), that no 
special visceral malady has excited the cutaneous disease. 

Pathology. — The researches of Hans Hebra 1 have demonstrated in 
two cases that there is, in the earlier period of the disease, an infil- 
tration of the integument moderate in degree, succeeded at a later 
period by cutaneous atrophy, in which the rete and papillse of the 
corium disappear. The connective tissue elements undergo sclerosis; 
and the glands and the follicles of the skin are destroyed. Pigmenta- 
tion is abundant. Both he and Fleischinan have discovered coinci- 
dent pulmonary, intestinal, or cerebral tuberculoses ; and Kaposi, in 
one post-mortem examination, established an atheromatous condition 
of the arteries. 

Baxter, 2 in a case examined bv him, discovered no trace of the 



i Vierteljahr. f. Derm. u. Syph., Hft. 4, 1876, p. 508. 
2 Brit. Med. Journ., 1879. 



PITYRIASIS RUBRA. 215 

stratum granulosum, nor was the stratum mucosum completely sepa- 
rated from the stratum corneum. There was a gradual transition 
from the polygonal prickle-cells below, which readily stained, to the 
horny cells above, which remained colorless. Flattened and faintly 
stained nuclei lay parallel to the surface, and could be recognized even 
in the enormously hypertrophied stratum corneum. The papillae 
were enlarged; the inter-papillary projections of the rete had pushed 
deeply into the corium. The prickle-cells of the hair-sheaths were 
multiplied. The remarkable consistency of the thickened corium at 
the outset of the disease, was regarded by him as chiefly due to a 
fluid exudate, which was observed before death. 

Diagnosis. — It is clearly necessary to add to the facts given above, 
that many cases loosely reported as instances of pityriasis rubra, are 
not really such. The misinterpreted symptoms are often those of an 
unusually extensive psoriasis or chronic squamous eczema, which 
commonly terminates favorably in the course of a proper treatment. 
Experts are often, summoned to see such eruptions, whose import has 
been misunderstood. 

In lichen ruber the essential lesion is a papule, which even in the 
later extensive scaling of that disease may usually be recognized in 
some part or another of the infiltrated skin. 

Psoriasis rarely extends over the entire surface of the body, but it 
will be at times thus generalized. In these very exceptional forms, 
a long history of typical psoriasic patches may usually be obtained, 
while the bleeding surface beneath the scales, and the character of the 
latter, will point to the true nature of the disease. Psoriasis occurs 
in healthy, pityriasis rubra in cachectic constitutions. Extensive 
erythematous or squamous eczema, apart from all other symptoms, 
can be recognized at once by the excessive distress occasioned by the 
eruption. The patient lies in bed nursing his or her tender limbs, 
back, or belly. In pityriasis rubra, the patient rises, dresses himself, 
and moves about with an expression, not of pain but of listless 
apathy. His scales are not scanty and adherent, but abundant and 
exfoliating freely. There is, from first to last in his case, no history 
of moisture. In every generalized eczema, there will be always, at 
one point or another, a surface which weeps. In its early periods, 
pityriasis rubra can be distinguished from pemphigus foliaceus by 
the absence of bullae, and of the intolerable stench which is then 
often emitted by the sufferer. When, however, there is present 
merely a generalized exfoliative dermatitis, the two disorders may be 
well-nigh indistinguishable. 

Treatment. — Arsenic administered internally seems powerless in 
pityriasis rubra. Cases are on record of fatal results after the exhibi- 
tion of this drug in prodigious quantities for long periods of time. 
Tar externally promises no better, Kaposi reports a single case 
relieved by the use of carbolic acid internally. 

A roborant treatment, including the employment of cod-liver oil, 
iron, or quinia, is certainly indicated, with the simplest bland unguents 
externally. Of the latter, vaseline seems best tolerated. It should 



216 DISEASES OF THE SKIN. 

be employed, not merely to soothe, but also to protect the skin. The 
clothing should he ample and unirritating ; and the diet carefully 
selected with a view to supporting the strength. 
The prognosis is necessarily grave. 

Lichen Planus. 



Gr. 1 



eix?/v, moss. 



Lichen Planus is a chronic and exudative affection characterized by the 
appearance upon the skin, of multiple, usually symmetrical, pin-point to 
split-pea sized, discrete or aggregated, Hat, polygonal, yellowish or pur- 
plish-red, smooth and glazed papules, having the appearance of umbilica- 
tion at the apex. 

Symptoms. — The first symptoms of the disease are the characteristic 
papules, which are glazed, waxy, umbi Heated, scaling at the apex 
only after they have existed for some time, pin-point to rape-seed in 
size, and roundish, angular, or oval in contour. They are usually 
firm, and particularly well characterized by the minute punctiform 
depression of the flattened apex, described as an "umbilication." 
They are at first irregularly disposed, but later tend to arrange them- 
selves in groups about the flexor aspects of the wrist and knee, the 
palmar and plantar surfaces, the lips, lids, cheeks, shoulders, penis, 
and other parts, as of the trunk and limbs. Often, as the lesions 
persist, they become flatter, assume a characteristic purplish-red or 
dark-brownish shade, and surround themselves with closely packed, 
newer lesions in circlets or parallel lines. In this way, distinct, 
sepia-tinted patches may form, whose progressive involution leaves 
dark-brown atrophic depressions in the skin, suggesting cicatrices. 
The itching may be moderate or severe. The eruption is chronic in 
its course; tends to linger for years within distinctly circumscribed 
areas, and seems to exert upon the constitutional forces little or no 
influence. As it is amenable to treatment, it has been less studied in 
its unmitigated features; but Kaposi thinks that in the majority of 
cases it would, if unstayed, become generalized. In one case only 
has he noted the occurrence of emaciation and other symptoms of 
disturbance of the general economy. 

Many lesions in the neighborhood of those well developed are the 
smallest papules recognized in diseases of the skin. They are no 
larger than the points of small pins, scarcely if at all elevated, and 
have either the color of the normal skin, or are whitish, lilac-tinted, 
or yellowish. They all, however, are, as Wilson first described them, 
"smooth, shining, and flat." The older groups may be either in 
circles or bands of various lengths having a violet, or bluish-red, or 
even a coppery hue. 

The other special characteristics of the papules are their angular 
outlines and the adherent horny covering of each. As to the former, 
the characteristic singularity of the sides is most couspicuous as the 
papule becomes developed ; but even in the exceedingly minute pin- 



LICHEN PLANUS. 247 

point sized lesions with a glass one may often detect the polygonal 
outline which later on can be distinguished with the naked eye. The 
surface of each is covered by a thin stratum of horny epidermis, 
which is not a true mass of scales since it does not exfoliate. In 
some types of the disease, a patch, whether band-like or circular, of 
aggregated and well-developed papules may include also an infiltrated 
interpapular skin, with a grade of inflammation which may result in 
severe general scaling, and with changes induced by the traumatism 
of scratching to relieve a consequent mild or severe pruritus. 

The course of the disease is decidedly chronic, but its lesions are 
never complicated by vesiculation, pustulation, or by changes in the 
hairs and nails. Upon the lower extremities, after it has existed for 
a long time, a single band-like plaque of the disease may lose almost 
all of the papular features, and come to resemble a deep purplish 
keloid-like elevation or flat tumor embedded in the skin, with whitish 
miliary points or streaks at the border. When involution is com- 
plete, there is usually very deep pigmentation and at times slight 
atrophy. 

Weyl describes the whitish points and streaks referred to above as 
visible at times even in the smaller lesions, the horny scales pro- 
jecting from others like thorns, and fantastic groups on the body in 
the form of a cockade or in a whip-shaped curve. 

Under the title Lichen Ruber Mouileformis, Prof. Kaposi 1 reports 
a curious form of this disease, in which the lesions were nearly 
symmetrically arranged upon the extremities, neck, and lower belly, 
and in which the papules were strung like beads along definite linear 
cord- like elevations. 

Lavergne divides all cases of lichen planus into three classes. The 
first is chronic lichen planus, the disease as it is known in its most 
common form. The second is acute lichen planus, in which the 
papules rapidly develop, and form extensive patches, thickened, 
painful, livid red, and abundantly desquamating. The third form 
is the lichen planus corneus of Vidal, Fournier, Besnier, and Heguy. 
It corresponds to the coin or palm-sized, bluish to blackish, scaling 
and rugous, tumor-like plaques, usually seen on the anterior face of 
the leg, briefly described above. 

Pospelow 2 and Thibierge 3 have observed buccal lesions occurring 
in lichen planus on the mucous surface. Wilson, Hutchinson, Kaposi, 
and Crocker have described similar lesions, which are to be carefully 
differentiated from the patches of leucoplakia buccalis (so-called 
"psoriasis buccalis"), epithelioma, and the mucous patches of syphilis. 
The plaques are whitish, thickened, and uniform elevations of the 
mucous surface, grayish-white, or resembling in color the places to 
which the nitrate of silver has been applied, with irregular contours, 
often horizontally disposed between the teeth. These may be due to 
confluence of pin-head size papules of lichen planus. 

1 Viertel. f. Derm. n. Svph., 1886, 4 Hft., with chromolithographic illustration. 

2 Viert. f. Derm. u. Syph., 1885, p. 533. 

3 Annal. de Derm, et de Syph.. 1885, p 66. 



248 DISEASES OF THE SKIN. 

Etiology. — The causes of the disease are obscure. It is seen in 
both sexes, and at all ages, but is decidedly more common in early 
and middle adult life. Debility, digestive disturbances, and neuras- 
thenia have all been named as effective causes; but it is seen in very 
fleshy middle-aged women and strong men. 

The evidence that connects this disease more directly with the 
nervous system is of great value, and annually accumulating. In 
some cases, distinct coincident neuralgias of the head and lumbar 
region are reported. In yet others the papules have been noticed 
distributed in the areas supplied by given nerves, or occurring after 
injury of such nervous branches. 1 

Pathology. — Robinson first clearly showed the pathological distinc- 
tion between lichen ruber and lichen planus. His observations have 
been confirmed by those of Bceck, Kaposi, Touton, Weyl, and others. 

The first changes noticed in the skin are increase in the lumen, and 
a sinuous condition of the capillaries supplying the one or two 
papilla? concerned in a single papule. The papilla?, thus largely filled 
with dilated capillaries, also contain a network of fine connective- 
tissue fibres, and dense, round cells, which proceed to multiply. Later, 
more papilla?, are concerned in this process and also the epidermis. 
In the places where the white points are exhibited, granules of kerato- 
hyalin become visible. In some portions of a lichen papule of 
medium development, the stratum corneum exhibits an external, dark, 
narrow, and firm layer, and beneath it two to four rows of translucent 
cells forming the stratum lucidnm ; but in other parts, and when fully 
developed in all parts, the stratum corneum breaks up into definite 
lamella?, a phenomenon seen in other disorders attended by derange- 
ment of the kerato-genetic function of the skin. The external layer 
is dark, when stained, and firm ; next below it is a wider layer of 
swollen cells with nuclei scarcely visible or relics of liberated nuclei ; 
and, still deeper, a narrow and solid layer beneath which the stratum 
lucidum becomes visible. 

In Robinson's sections, the horny layer was almost entirely absent 
over the region occupied by the cell-packed papule, below which the 
corium was normal. The rete was hypertrophied centrally, especially 
in the region of the sweat-ducts; its cells above the affected papilla? 
horizontally flattened, and the granular layer thickened. In some 
places it was difficult, in consequence of these changes, to distinguish 
between the rete and the corium beneath. The cell-infiltration, com- 
posed largely of embryonic white blood- corpuscles, extended more 
deeply into the corium in the neighborhood of the sweat-ducts. 

Briefly, it appears that the papule of lichen planus is the result of 
a primary hyperemia of the papilla? of the corium ; a secondary 
thickening of the lower part of the rete ; a tertiary flattening of the 
papule by reason of the resulting pressure, producing thus the appear- 
ance of umbilication ; a proliferation of cells in the granular layer, as 
a result of which the deposit of kerato-hyalin in whitish points or 

1 See Keport of Two Cases, by Dr. Stephen Mackenzie, Journ. of Cutan. and Yen. Dis., 1885. 



LICHEN PLANUS. 249 

sheets occurs sufficient to produce the clinical peculiarities having that 
appearance (not due, as Neumann supposed, to changes in the sweat- 
glands) ; and coloration of lesions due to both vascularization and to 
escape of blood corpuscles. 

Diagnosis. — The diagnosis rests on the characteristic shape, size, 
color, grouping, disposition, and umbilication of the papule of lichen 
planus ; which are not found in any other papular disease. Thus, in 
its size, apex, color, and course, the papule of papular eczema is quite 
different from that described above, being brighter, redder, more 
acuminate at the apex, and much more often followed by or accom- 
panied by catarrhal symptoms. In psoriasis punctata, the scales are 
abundant and readily removed ; the individual lesions also increase 
rapidly by peripheral extension, far beyond the fullest development of 
the papule of lichen. The papular syphiloderm is not pruritic, not 
flattened when minute, not polygonal in shape, not covered with a 
closely adherent horny scale, and always occurs in patients where 
careful investigation will disclose other symptoms of the disease 
(mucous patches, adenopathy, etc.). 

Treatment. — Roborant treatment by quinine, the mineral acids, the 
ferruginous tonics, and cod-liver oil, is frequently indicated. Though 
it is claimed that arsenic actually aggravates the disease, the author 
agrees with Hebra, Wilson, Duhring, and others, in ascribing to it 
the most brilliant results obtained in the treatment of lichen planus, 
results far more consistent than are obtained from the same drug in 
the management of psoriasis. Boeck and Taylor give fifteen 
grains (1.) of the chlorate of potassium in four ounces (128.) of water, 
fifteen minutes after eating, followed in a quarter of an hour by 
twenty drops of the dilute nitric acid, swallowed in a wineglassful of 
water. Robinson, in generalized and hypersemic cases, praises the 
alkaline diuretics (acetate of potassium with sweet spirits of nitre), 
well diluted after meals ; and Fox regards mercury as valuable in 
the chronic forms of the disease, for which also he administers 
asafoetida. 

Finally, Koebner has injected both pilocarpine and arsenic sub- 
cutaneously with success ; Unna has used one part of corrosive subli- 
mate, twenty parts of carbolic acid, and five hundred of the benzoated. 
oxide of zinc salve ; Vidal employs baths of vinegar, one litre to the 
bath ; and the external application of one part of tartaric acid to 
twenty of the glycerine of starch ; and Wilson employed a mercurial 
salve two grains (0.13) to the ounce (32.). Tar, ichthyol, thymol, 
iodine, and chrysarobin may also be successfully employed topically. 
Weyl has employed caustic applications ; as also one to two parts of 
(3 naphthol to ninety of rectified spirits of wine, and ten of glycerine. 

Prognosis. — The prognosis is always favorable, as the disease, even 
when chronic, tends to spontaneous disappearance. 



250 DISEASES OF THE SKIN. 

Lichen Ruber. 

Gr. Taixfyv, moss. 

Lichen Ruber is an exudative cutaneous disease, characterized by the appear- 
ance of firm, millet-seed to split-pea sized, reddish, conical, discrete, or 
confluent papules, whose evolution may be accompanied by a moderate 
degree of itching, the eruption having a marked tendency to generalization 
and the induction of a fatal marasmus. 

Under the terra Lichen Ruber, Hebra was first to describe the dis- 
ease which is now recognized under this title, and which was, at one 
time, thought to include lichen planus, the two diseases being merely 
different expressions of a single pathological process. It has been 
already shown that lichen planus, which is much the more common 
of* the two, has no relation with lichen ruber. Very few cases, indeed, 
of the last-named disease have ever been reported in this country ; 
and there are authors who deny its existence as an independent affec- 
tion, claiming that the conditions described under the name should 
be properly assigned to other categories. 

Symptoms. — The disease is first characterized by the appearance, 
without prodromal symptoms, of isolated, pin-head sized, conical, 
reddish, and scale-capped papules of considerable firmness, bright red 
or livid in hue, and disseminated over the belly, chest, genitalia, 
extremities, and other portions of the body. In another form of the 
disease, these lesions are lighter in color, with a smooth surface, a 
small central depression at the apex, and a waxy appearance. It is 
these latter which have suggested that lichen planus is a variety of 
this disorder. The itching excited may be mild or severe. It bears 
no relation to the extent of the exanthem. 

The papules rapidly multiply, forming patches which by aggrega- 
tion eventually cover entire regions of the body, and, lastly, its entire 
surface. Throughout all, the individual papules do not enlarge at the 
periphery, but persist as such till they are lost in a diffuse, dull-red, 
infiltrated patch, covered with thin, papery, grayish, non-adherent 
scales, beneath which the orifices of the hair-follicles are seen to be 
dilated. 

Occasionally at the borders of a patch thus formed, isolated, shining 
flattened, or umbilicated papules persist or form circles of densely 
packed lesions, surrounding groups in which involution of the lesions 
progresses, leaving pigmented and atrophic areas within. 

Whether in the form of the lesions last described, or after irregu- 
larly disposed disseminated patches have been developed, the entire 
integument becomes eventually the seat of extensive infiltration, 
reddening, and scaling As a consequence fissures form ; and t the 
distress of the patieut increases. 

The skin of the face cracks ; the lids are everted or thickened ; 
the skin of the palms and soles is converted into leathery tissue; the 
nails become friable and irregular ; motion at the joints is excessively 
painful, on account of the inelasticity of the skin covering the articu- 



LICHEN RUBER. 251 

lations ; the hairs are thinned and fall ; the extremities are maintained 
in a position midway between flexion and extension. The integument 
is now universally reddened, covered with innumerable delicate or 
coarser scales, and, especially upon the palmar and plantar surfaces, 
thickened by dense infiltration. Over the deeper fissures, extending 
to the corium, blackish and blood-containing crusts form. Emacia- 
tion progresses pari passu with the invasion of the disease; and death 
may result from exhaustion, an intercurrent diarrhoea, or a pneu- 
monia. 

Etiology. — The causes of the disease are unknown. The sexes 
seem to suffer in equal proportion, though it is claimed that more men 
than women are affected. The disease is neither transmitted by 
heredity nor contagion. In those who display the symptoms of the 
affection, external irritation is capable of aggravating the eruption. 
The disease is chiefly encountered in middle life from the tenth to 
the fortieth year, but has been observed as early as the eighth month. 

Diagnosis. — In psoriasis the discovery of a typical scaling patch, 
often with a clearing centre, should suffice for recognition of' that 
disease. The scaling also in diffuse psoriasis is much more abundant. 
In papular eczema, the lesions do not persist as such. When these 
two affections are generalized, it is claimed by French observers 
that there is always some one area, however small, of unaffected 
integument. This is not true of generalized lichen ruber. But, in 
such generalized cases, the distinction between that disease, pityriasis 
rubra, and dermatitis exfoliativa may be extremely difficult, if at all 
practicable or possible. At an earlier period, papules are not seen in 
either of the two last named disorders. The papules of syphilis 
never scale so generally as those in lichen ruber ; they, moreover, in 
cases, increase to double their original size ; and are always accom- 
panied by some other symptom of that disease. In the scaling stage 
of pemphigus foliaceus, there are bulla? present or a history of such 
lesions preexisting. 

Pathology. — According to Robinson, lichen ruber is a paratypical 
keratosis. It is characterized by hypertrophy of the stratum corneum 
and incomplete corneous transformation of the individual elements of 
that layer, which are larger and more polygonal, a feature most 
noticeable about the sweat-ducts and hair- follicles. The rete is in 
places enlarged and in places normal. The upper portion has an 
uneven appearance as the interpapillary portion pushes slightly clown- 
ward and the increase in size of the other parts is more marked. 
The papilla? are increased in size ; their bloodvessels dilated and 
surrounded by emigrated corpuscles. The walls of the sweat-duct 
are formed of large cells with vesicular nuclei ; corneous cells are 
heaped also about the orifices of the hair-follicles : the muscle-bundles 
are much hypertrophied. 

Treatment. — Arsenic is of greatest value and can be employed with 
large chances of success in lichen ruber. The drug is to be early 
given, persistently pushed in the face of new crops of lesions, till the 
desired result is obtained, and continued for several months after all 



252 DISEASES OF THE SKIN. 

signs of the disease have disappeared. Tonics when indicated, should 
always be exhibited. The diet should be generous. 

The external treatment is naturally employed chiefly for the relief 
of any pruritic sensation. Here the dusting powders and ointments 
prove serviceable. The local remedies employed in corresponding 
stages of eczema may, in brief, be here used with advantage, such as 
the alkaline, starch, or bran bath ; and followed by inunction of the 
skin with salves containing thymol, salicylic acid, zinc oxide, bismuth, 
carbolic 1 acid, or benzoin. 

Prognosis. — The prognosis of the disease, when it refuses to yield 
to treatment and tends to become generalized, is necessarily grave. 
Treatment after the occurrence of marasmus, will often prove in- 
effectual. The disease is said to be occasionally amenable to energetic 
treatment before it lias advanced to the stage of inducing systemic 
exhaustion. 

Eczema. 

Gr. £k fi'w, to boil forth. 

Eczema is a non-contagious, acute, or more frequently chronic, inflammatory 
disease of the skin, beginning as an erythema, or by the appearance of iso- 
lated or grouped papules, vesicles, or pustules, either singly, simultaneously, 
or in succession, resulting in redness, catarrhal symptoms, scaling, crusting, 
and infiltration of the skin, accompanied by more or less intense itchiug 
and burning sensations, and leaving, after complete resolution, no cicatrices. 

Symptoms. — Eczema is one of the diseases of the skin of most 
frequent occurrence. In the statistics gathered by medical men, it 
would seem to rank first in the order of frequency. But it is only 
true as regards those diseases for which the physician is commonly 
consulted. It is easy to become convinced that acne is a more fre- 
quently encountered affection than eczema, by observation of the faces 
of individuals on the streets of any large city, eczema being of more 
frequent occurrence in this situation than upon other parts of the 
body. Many persons are the subjects of acne who never deem it 
necessary to submit to treatment for its relief, and the records of such 
cases do not figure in dermatological statistics. This being noted, 
eczema may be regarded as the disease of the skin for which most 
frequently the practitioner of medicine is consulted. By as much as 
inflammation is the most common accident of other organs of the 
body, by so much is its enveloping organ subject to the same patho- 
logical process. 

The surgical signs of inflammation of any given tissue are usually 
named as increased heat, redness, pain, and swelling. These are 
essentially the symptoms of an eczema; and it will be necessary, in 
order to study the disease intelligently, to inquire how these pheno- 
mena are modified by the anatomical peculiarities of the organ in 
this case affected A typical eczema is always betrayed by an eleva- 
tion of the temperature of the surface, and by a greater or less 



ECZEMA. 253 

degree of swelling. Redness, in various shades, is also true of the 
eczematous skin. Pain here is represented by a sensation usually of 
itching, which may vary from slight annoyance to an almost intoler- 
able distress. The variation in the sensation which accompanies 
inflammatory disorders of the skin and other organs is merely due 
to the fact that the former is exposed to the air, and its increase in 
bulk is not opposed by other contiguous parts, as, for example, the 
inflamed bone in contact with periosteum, or the pathologically 
enlarged prostate within its fibrous capsule. Inflammation of the 
inner skin of the body, as of the lining membrane of the stomach or 
of the intestines, is generally characterized by the occurrence of in- 
creased heat, redness, swelling, and severe pain. 

Inflammation of tissues constituting other organs of the body 
usually terminates either in resolution, in the free production of pus, 
or in the occurrence of gangrene. And so an inflammation of the 
skin may terminate either by resolution, or by the free production of 
pus on its surface, the living matter rapidly multiplying as the in- 
tensity of the process may determine. Gangrene is not a classical 
result of eczema, chiefly because of the freely exposed position of the 
organ affected. 

The great variety of expressions assumed by an eczematous dis- 
ease, and the frequent interchange of these, the one for the other, are 
to be accounted for in the same way. The atmosphere which sur- 
rounds the body is but one of many external influences capable of 
affecting the skin. Thus it is rubbed and scratched, exposed to the 
friction of the clothing and the incursions of insects, and subjected 
to innumerable injurious contacts in all the various trades and occu- 
pations of life. If the inflamed skin could be as perfectly protected 
from the outer world as is the spleen, we should find the history of 
this affection much simplified. 

Clinically, several types of eczema can be recognized. These require 
separate description. It should not be forgotten, however, that each 
may prove to be not a variety, hut a stage of the disease, which may 
speedily give place to yet another. 

[A.] Eczema Erythematosum. 

In this form of the disease the conspicuous symptoms are heat, 
redness, and swelling, with a variable degree of itching, usually less 
severe than in several of the other phases of the malady. The pro- 
cess may begin with acute and intense symptoms, to be soon followed 
by one of the varieties of the disease to be subsequently described, 
or, what is perhaps more commonly the case, may continue indefin- 
itely as a subacute or even chronic affection. In color the skin of 
the part involved varies from a light to a darker shade of red ; and 
inasmuch as the process is more frequently observed in middle-aged 
adults, with darker hue of the integument than in early life, the 
color of the part is frequently noticed to be of a dull shade. In 
consequence of the swelling, the affected surface is notably elevated 



254 DISEASES OF THE SKIN. 

above the level of the unaffected contiguous skin, and the line of 
demarcation between the two can be more readily traced than in 
several of the other varieties of eczema. The surface is usually 
uniformly and occasionally symmetrically involved. Lesions, other 
than the erythema, which is the prominent feature of the attack, may 
not be observed; and, as a consequence, from the beginning to the 
end of the disease, there may be no history of moisture. But in many 
cases, minute poppy- to rape-seed sized papules become visible on close 
inspection, still more rarely with a very minute vesicular apex filled 
with a droplet of clear serum. The localities chiefly thus involved 
are the face, the palms, the soles, and the regions about the genitalia, 
though any portion of the body may be affected. Resolution is 
accomplished after the occurrence of a very fine superficial desquam- 
ation of the epidermis, or by very gradual diminution of the red- 
ness and swelling without the production of scales. In either event 
the termination of the process is often announced by significant 
changes in the involved surface, as by the fading of color, the ap- 
pearance of islets of sound skin between affected patches, and by 
perceptible relief in the subjective symptoms. 

Such is the course of a typical erythematous eczema. Variations 
from this type are, however, numerous and important. Thus the 
disease may be limited to a patch as small as a finger nail, or may 
extend over large areas, especially after subjectiou to irritation. At 
times the coloration is irregularly distributed, producing a mottled 
appearance, brighter at one point and darker at another, while again, 
as has been indicated, the variety described may coexist with, or be 
followed by, the weeping, excoriation, and crusting which are charac- 
teristic of other manifestations of eczema. Scratching of the part 
involved produces a change in the symptoms which the skilled eye 
will promptly recognize. Minute superficial losses of tissue are then 
visible here and there upon the surface ; the fresher with a reddened 
floor possibly hidden beneath a thin blood-scale, the older surmounted 
by a light yellowish-red crust. The scratch-lines, so often recogniz- 
able elsewhere, are here less frequently evident. 

Like all the other varieties of eczema, this is extremely liable to 
recrudescence and relapse. In advanced life, the traces of the dis- 
ease may be visible for years. 

[B.] Eczema Papillosum. 

Under this title are classed all those forms which have long been 
described as Lichen Eczematodes, Eczema Lichenoides, etc. 
"Observation of the natural course of an attack of eczema," says 
Hebra, "furnishes the most unassailable proof of the connection 
between its various forms. Iu one case an eruption of vesicles begins 
the series of symptoms ; in another, it is preceded by the appearance 
of red scaly patches or groupes of papules ; or vesicles and papules 
are developed together, some of the former rapidly changing to pus- 
tules, and forming yellow gum-like crusts by the drying up of their 



ECZEMA. 255 

contents." It is of the greatest importance that there should be a 
distinct aud more general recognition of the fact, that eczema may 
exist from first to last as a dry infiltration of the integument, for 
there is perhaps no one of the various manifestations of the disease 
that is so frequently mistaken, and confounded with other widely 
different affections. 

The poppy- to rape-seed sized papules which are developed in its 
course, are usually seated upon a reddened and thickened base, and 
are themselves colored in various shades of red to a dark lurid shade. 
They are usually discrete, though often closely set together; are 
accompanied by a severe form of itching when irritated by scratching, 
aud of all eczematous lesions are most apt to be thus irritated. Their 
summits are toru, and often to such an extent as to bleed, the blood 
drying in reddish crusts over the area involved, or limited to minute 
blood-scales on the apices of individual lesions. The extent of sur- 
face affected varies, as usual in the other varieties, being in cases 
largely diffused in patches over various portions of the body, or 
limited to small and single patches no larger than a silver quarter of 
a dollar. Such patches, covered with a single or several groups of 
reddish papules, may continue to torment the patient for long periods 
of time, or, being at one time relieved, recur with each aggravation 
of the part by the exciting cause. Papular eczema is the dry mani- 
festation of the disease, and is thus most frequently noticed upon the 
drier portions of the integument. These are the surfaces of the 
limbs, the back of the body, and, in particular, the scrotum. In the 
latter region, the lesions giving a name to this variety of the disease 
are most fully developed. If the moist forms of eczema are most 
frequently seen in early life, it is none the less true that the dry forms 
are most common in adult life or advanced years. 

It should not, however, be forgotten, that the papules here described 
may develop into minute or larger pustules, or may exhibit minute 
vesicular summits when there is free exudation beneath the surface. 
It should be added, that a patch of papular eczema, where no vesicula- 
tion nor pustulation has been observed, will, if sufficiently scratched, 
ooze with moisture, the serum escaping from the abraded surface. 
There are, in fact, few scratched eczematous surfaces which will not 
moisten a dry handkerchief applied to the part. This weeping con- 
dition attracts the attention of patients themselves, who Mall complain 
of it in describing their symptoms to a physician. A certain species 
of relief for the pruritus is thus obtained ; and in aggravated cases 
patients will scratch, or rub, or otherwise irritate their diseased 
patches, not merely for the purpose of gratifying the intense desire to 
assuage this symptom, but also to induce the serous exudation for the 
sake of the relief it affords. The secretion when in contact with 
linen cloths stains and stiffens them, very much as seminal fluid 
leaves its traces upon the clothing. 

Resolution of papular eczema is accomplished after the formation 
of scales, the tissue beneath the latter assuming more and more the 
appearance of healthy skin. 



256 DISEASES OF THE SKIN. 

[C] Eczema Vesiculosum. 

This variety of the disease is, as its name implies, characterized 
at an early period by the formation of minute vesicles. It is a matter 
of importance, however, to recognize the fact that the vesicular, like 
the erythematous, is but one of several manifestations of this singu- 
larly protean affection. Long after the appearance of the treatises of 
the early English dermatologists, the term eczema was very generally 
limited by physicians to the vesicular phases of the disease; aud it is 
to the Vienna school that we are largely indebted for the recognition 
of the fact that these simultaneous or successive features, presented 
often in the same individual, really belong to one and the same malady. 
To limit the name eczema to-day to its vesicular variety alone would 
be to relegate the student of diseases of the skin to the misty uncer- 
tainties of the last half century t)f dermatology. 

The clinical features of vesicular eczema are chiefly due, first, to the 
acuity of the inflammatory process present; and second, as the result 
of the former, to the free exudation of the serum of the blood from 
the vascular plexus immediately below the pars papillaris of the 
corium. The involved surface usually feels at the outset hot, itchy, 
or particularly sensitive, and soon after becomes more or less intensely 
reddened, the hyperemia producing this effect in the course of a 
true exudation which may last for one or several hours. Poppy- to 
rape-seed sized vesicles then become visible on this reddened base. 
The lesions may be closely packed together, or discrete, or may be 
so abundant as to coalesce, a frequent behavior of all vesicular 
lesions. Each is filled with a droplet of clear serum, imprisoned 
beneath the most superficial layers of the epidermis. The vesicle is 
readily ruptured, and, if this does not speedily occur as the result of 
accident, it bursts spontaneously, and its limpid contents are then 
poured out upon the surface of the integument. The quantity of 
the fluid thus exuded is in excess of that originally contained in the 
small vesicular chamber. This is due to the fact that the elevated, 
macerated, and broken epidermis no longer presents an obstacle to 
the outflow of the serum from the engorged vessels beneath. Minute 
and even large drops of a clear fluid of syrupy consistency can be 
seen forming at the points where the solution of continuity has 
occurred. If with a slip of bibulous paper the first drop be removed, 
its place is visibly filled by a second. Crops of new vesicles succeed 
the first, each followed by the train of symptoms described. The 
weeping at many points of the surface thus affected, is so promineut 
a feature of the disease that it has led several authors to describe 
eczema as invariably a catarrhal disease of the skin. There are, 
without question, forms of the disease where the history is throughout 
entirely different from that just described, where no evidence of 
discharge can be appreciated from first to last, and yet where, by 
artificial measures, the so-called catarrhal features can be readily pro- 
duced. 

The subjective symptoms of the vesicular forms of eczema are more 



ECZEMA. 257 

or less intense itching and often burning. In the very acute forms 
there is considerable soreness, the patient managing the aifected part 
with as much care as if it were a fractured limb. In exceptional 
cases, more frequently observed in children, there is sympathetic 
febrile disturbance of a mild grade. 

The discharge from the broken epidermis, whether directly from 
the vesicles, or from the vascular elements, dries rapidly when exposed 
to the air, in light yellowish crusts, which are rarely bulky. The 
extent of surface involved is variable, and the contour of the affected 
patch or patches is seldom well defined, these portions imperceptibly 
shading into the sound skin. The color of the area thus diseased 
varies according to the stage of the process, being at one time of a 
bright and vivid red, at another yellowish, and when covered with 
crusts or scales, undergoing a corresponding change of hue. Infiltra- 
tion of the skin occurs rapidly, so that when a portion of the affected 
integument is pinched up between the finger and thumb, it is found 
to be thicker and less elastic than before. 

As resolution approaches, all the symptoms described above grad- 
ually decline in severity : the serous discharge diminishes, the redness 
fades, the limits of the involved area are less distinct, the crusts 
loosen and fall, and it can be seen that beneath the scales which 'have 
taken the place of the oozing and broken epidermis, a new and tender 
epithelial covering has been produced. As a rule, for weeks after 
the process has completely ceased, the newly formed epidermis has a 
slightly reddened and tender appearance, though complete resolution 
is followed by no permanent sequelae. 

Such then being the typical phases of vesicular eczema, it must not 
be forgotten that clinically the picture may be quite different from 
that described. The types here given are convenient for analysis 
and study, however they may be commingled and obscured in the 
inflamed integument. Like the erythematous, the vesicular forms of 
eczema may precede the others, and becoming chronic, torment the 
suffering patient continuously for long periods of time, or yield, only 
to reappear at irregular intervals. 

[D.] Eczema Pustulosum. 

This variety of the disease may originate in one of the other forms 
of eczema, which, in consequence of the severity or acuity of the 
process, changes from an erythematous, papular, or more commonly 
vesicular type, or the pustular lesions may rapidly form at the onset. 
Usually a crop of minute vesicles is first seen of the sort just 
described, which, after enlarging to the size of a coffee-bean, become 
distended with puriform contents. These either accidentally or spon- 
taneously burst, and the fluid with which they were distended dries 
into yellowish-green or darker-colored and friable crusts. In aggra- 
vated cases the purulent matter seems to form directly upon the sur- 
face involved. If the process be long continued, infiltration occurs ; 
and the itching, which in all varieties of the disorder is a charac- 

17 



258 DISEASES OF THE SKIN. 

teristic feature Is awakened as an accompanying symptom. It is, 
however, rarely of the peculiarly aggravated type which accompanies 
the erythematous and papular phases. Pustular eczema is most fre- 
quently encountered in the regions of the head, and in constitutions 
where there is a pyogenic tendency. When existing on the scalp 
and line there is most commonly an involvement also of the sebaceous 
glands, whose secretion, altered by the periglandular inflammation, 
is added to that naturally produced by the exudative process. 
Singular shades of mixed yellow and green, and even black, are then 
to be distinguished in the resulting crusts, which later desiccate and 
fall, leaving a reddened and tender new epidermis beneath. 

Pustular eczema, as thus observed, has been described under a great 
variety of titles. Its identity as a form of eczema was first accurately 
distinguished by Hebra, in his experiments on the artificial produc- 
tion of the disease upon the surface by the external application of 
crotou oil. It has been called Impetigo Figurata, Meleitagra, 
Porrigo Larva lis, and other singular names, which suggest the 
attempts of the early astronomers to designate the constellations by 
their resemblance to the figures of animals. These, and many other 
useless terms, have been finally dropped from the nomenclature of 
modern dermatology. 

The four types of eczema considered above are, as has been stated, 
sometimes encountered in practice as distinct and unmingled forms 
of cutaneous disease, some of them more commonly than others. 
To present, however, a picture of eczema as it is seen clinically, it 
must be understood that these several forms, useful in the analytical 
study of the disease, often become, in actual observation, well nigh 
inextricably commingled. It is this untiring interchange of features 
which distinguishes all the results of manifold causes operating in 
nature at one and the same time; and it is this which gives the 
inflammations of the human skin, exposed to almost every external 
influence, such a manifold physiognomy. 

Like all other inflammations, eczema may be acute or chronic. 
Like all others, too, the acute may precede, and the chronic follow ; 
or the reverse may occur, the disorder, originating in subacute or 
insidious forms, may become chronic, and then, as the result of fresh 
or more severe irritation, develop into the acutest symptoms. Thus 
the name 

Eczema Rubrum 

has been given to the red and angry form of the disease, which, 
because of the free exudation of serum from its surface, has been also 
termed Eczema Madidans. In this form, the intensely red and 
wounded integument pours out freely upon the surface a thick gummy 
or syrupy fluid, which, if artificially removed, leaves behind it the 
swollen, angry, and still discharging skin, or, being permitted to dry 
where it has formed, concretes into the thick, dark-colored and often 
blood-stained crusts already described. 

Again, the scales which usually form on the eczematous skin toward 



ECZEMA. 259 

the conclusion of the process jnst described, may prove to be the 
most characteristic feature of the case from the first. Thus on the 
back of the neck an eczematous patch may often be seen, where the 
skin is infiltrated and covered with a stratum of thin, whitish scales, 
the latter having developed rapidly upon an erythematous surface, 
and continuing for a long period as a scaly disease. It is to this and 
similar forms that the term 

Eczema Squamosum 

has been applied. Again, in the regions about the hand, the move- 
ments of that organ develop often fissures or cracks in the inflamed 
and infiltrated integument, and to these fissured forms the term 

Eczema Eissum, or Eczema Rhagadiforme, 

has been applied. They are observed wherever an eczematous dis- 
order has so impaired the elasticity and extensibility of the skin, that 
its necessary movements, especially about the joints, tear and stretch 
the torn integument. It is thus seen not only on the hands, but also 
on the feet and about the ankles, the resulting rhagades being, at 
times, the most painful of all the complications of the malady. 
Occurring upon the bodies and the hands of those who are compelled 
to come into contact with irritating substances, this form of the dis- 
ease finds its severest expression. 

Eczema Intertrigo 

is a name applied by several authors to that form of intertrigo which, 
surpassing the limits of hyperemia, results in an exudative process. 
Reference was made to this possibility in describing the symptoms of 
erythema intertrigo, in a preceding chapter. Here the symptoms 
are usually those of dhTused redness of surfaces of the skin in close 
apposition, macerated by previous transudation of sweat, and weeping 
with the serum which oozes from the several abraded points or patches. 

Eczema Verrucosum, 

or the wart-like form of the malady, is occasionally observed, espe- 
cially upon the lower extremities, in middle life or advanced years, 
as the result of long-continued disease. The integument becomes 
thickened and so hypertrophied as to suggest the appearance of warts 
closely packed together in a circumscribed patch. 

Eczema Sclerosum 

is a form of the disease most frequently observed upon the palmar 
and plantar surfaces, a condition referred to in the paragraphs relating 
to asteatosis. Here is presented a densely thickened inelastic in- 
tegument, suggesting the condition of tanned leather, without the 
occurrence of any of the other lesions of eczema described above. As 
a consequence, the perfect extension of the digits is impaired. 



260 DISEASES OF THE SKIN. 

Most authors agree in considering eczema as it occurs in its acute 
and chronic manifestations. These are, as has been seen, inter- 
ehangeable conditions, the types of which possess, however, a clinical 
distinct in,—. 

Acute Eczema. 

In certain cases an acute attack of the disorder is ushered in by 
malaise, chilliness, or the recognized symptoms of the febrile state. 
With or without these prodromata, the affected portion of the surface 
becomes the seat of a burning sensation which is soon succeeded by 
redness and swelling. This may occur upon one or several portions 
of the body at the same moment of time, and the disease throughout 
be limited to this single area or those several spaces; or it may extend 
from one or all to other regions. This extension may proceed by 
continuous development of the disease along the surface, or an eczema 
of the thigh be suddenly followed by an eczema of the face, and this 
by an eczema of the scrotum. According to Kaposi, extension of 
eczema by the last-described method is due to the extraordinary sen- 
sitiveness of the skin when involved in an acute attack, in con- 
sequence of which the slightest friction, and even reflex irritation of 
the bloodvessels, produces a new focus of the disease at a distant point. 

This is a consideration of special importance. Patients will fre- 
quently point to an acute eczema upon several portions of the body 
widely separated, the one from the other, and urge this as an irrefutable 
argument in favor of the fact that they suffer from some " poison in 
the blood." 

The tumid and erythematous surface already described soon 
assumes the features of either papular or vesicular eczema, which need 
not be again detailed. In this manner the evolution of the disease 
occurs, and may continue for weeks, the patient, if unrelieved, tor- 
mented by the itching; and, if the disease be extensive, prevented 
from attending to his usual avocations. Acute eczema of severe grade 
will frequently prostrate a strong adult, confining him to his bed- 
chamber and often to his bed. When there is a simultaneous febrile 
process, the emaciation and adynamia are proportioned to its severity. 
Weeks and even months may elapse before recovery can be pro- 
nounced complete, subacute patches of the disease lingering here and 
there upon the surface, crust-hidden, scale-covered, occasionally oozing 
from recrudescence of symptoms. Recovery, even when complete, 
leaves the patient, it should never be forgotten, with a skin sensitive 
to irritation and more prone to a fresh attack of the disease than one 
long virgin of an inflammatory process. 

Such is the course of an attack of acute eczema of severe grade. 
Needless to say that a circumscribed patch of the skin may exhibit all 
the features of vesicular eczema in an acute form ; and, under the 
influence of an appropriate treatment, be satisfactorily relieved in 
the course of a few days. Lastly, acute eczema may be followed by 
chronic forms of the disease, the one passing into the stages of the 
other by scarcely definable gradations. 



ECZEMA. 261 

Chronic Eczema. 

The symptoms and pathology of chronic eczema are largely those 
of the acute form of the disease. The chief differences to be noted 
relate to diminished intensity of the inflammatory action, or marked 
tendency to recurrence and persistence of the process, and a pre- 
ponderance of scaling and infiltration as contrasted with the active 
secretion and crusting of the acute phases. It is, however, important 
to remember that chronic eczema is not only the frequent sequel of 
such acute phases, but is particularly prone to recurrent exacerbations 
of acute grade, during which the serous discharges, consequent crusts, 
and angry aspect of the affected surface, do not fail to reappear. 
The itching so characteristic of the malady in all its manifestations 
is here also a tolerably constant symptom. 

Chronic eczema may involve a limited surface of the skin, or 
invade the entire surface of the body from the head to the feet. 
Rarely thus generally developed, it is more frequently observed upon 
circumscribed patches of the integument, as, for example, the scrotum 
or flexor surface of a joint, in which situation it may linger for years, 
or even for a lifetime, now better and now worse, or disappearing 
for brief periods only to return with each recurrence of its cause. 

Etiology. — Eczema is a disease of both sexes and of all ages ; and 
is, moreover, neither contagious nor inherited. The study of its 
etiology is thus to a degree simplified. 

In many cases no cause of eczema can be discovered, beyond those 
which operate exclusively within the skin-organ, and are proper to 
itself. These are necessarily obscure, and will remain so until we 
are in possession of far more knowledge as to the complex and 
inscrutably delicate processes by which innervation, nutrition, and 
new formation of the living matter of the skin, are both conserved 
and impaired. The autonomy of the integument must be conceded 
to the extent recognized in other organs of the body. There are 
diseases of the liver which are neither referred to the blood, the 
nerves, nor the action of poisons. There are diseases of the heart 
which can be induced by neither rheumatism nor syphilis. When 
the etiology of the disorders of all the viscera is perfected, that of 
the skin displaying the lesions of eczema will be assuredly more 
distinct. 

These remarks are justified by clinical facts. Eczematous affec- 
tions occur in the persons of individuals who are in every respect 
superb examples of good health, where the most thorough and careful 
examination fails to reveal for the disorder either an external or in- 
ternal cause. Eczema occurs also in persons who are affected with 
every form of bodily ailment ; those suffering from acute and chronic 
disorders of every viscus and system of the body ; and even those 
affected with other disorders of the skin. This is only what a study 
of established facts would suggest, having in view the probable pro- 
portion of eczematous attacks in every thousand individuals. Such 
coincidences would, however, scarcely furnish a satisfactory etiological 
basis for the disease, unless a certain degree of constancy between 



262 DISEASES OF THE SKIN. 

eczema and these disorders could be established. Thus eczema is 
often seen in patients affected with rheumatism, gout, dyspepsia, 
malaria, obstinate constipation, anaemia, scrofula, and pulmonary dis- 
orders, a list of affections exhibiting surely very wide pathological 
differences. Yet he would prove to be a physician of exceedingly 
limited experience who could not select from patients under his own 
observation, twenty individuals affected with any one of the diseases 
oamed, no .-ingle person of the entire number having ever exhibited 
symptoms of eczema. If figures alone were to decide the question, 
these, and a larger list of maladies which have been named in similar 
connection, would be excluded in the study of the etiology of the 
disease. 

As predisposing causes, those operating by inducing systemic 
debility, many if not all the diseases named above, may be effective. 
In this way, chlorosis, albuminuria, tuberculosis, struma, gout, rheu- 
matism, uterine disease, dyspepsia, hepatic disease, constipation, and 
other gastro-iutestinal disorders may lay the foundation for a per- 
sistent eczematous attack. In a similar way it is possible that a pre- 
disposition to this disease may be inherited, but, as distinguished 
from all the diseases known to be transmitted by heredity, it may be 
asserted that no child was ever born into the world with an eczema. 

Eczema seems, in exceptional cases, to bear some relation to spas- 
modic asthma, sometimes coexisting with that disease in one person, 
or its attacks alternating quite regularly with the asthmatic parox- 
ysms. This may be due to the exquisite sensitiveness of the skin, 
mucous membranes, and nervous system exhibited in some patients. 

The so-called internal causes of eczema must be, for reasons given 
above, considered for the most part as either coincidences or condi- 
tions which favor the development of diseases in general, eczema not 
excepted. By interference either with innervation, nutrition, develop- 
ment, excretion, or the performance of the important functions of the 
body, as well as by reflex irritation of the surface, they operate by 
inviting, aggravating, or prolonging an eczematous attack. Among 
these may be named : not merely the diseases enumerated above, but 
also as physiological states, pregnancy, lactation, and dentition ; as 
associated with the habits of life, occupations necessitating inordinate 
fatigue of body or mind, especially with the exclusion of sunlight ; 
and lastly, as originating in the irritative action upon the mucous 
surfaces, of substances foreign to the body, dietary and medicinal 
articles capable of exciting cutaneous rashes, intestinal parasites, and 
instruments inserted and fluid injected into the mucous canals, as, for 
example, the male urethra. 

This much premised, it should be added that every phase of 
eczema can be artificially produced upon the surface of the skin by 
the action of external irritants. Several authors, notably those of 
French nationality, take exception to this view, claiming that the 
induced disease in such instances is an artificial dermatitis, but they 
fail to point out the distinctive objective differences between such 
dermatitis and eczema. They content themselves with observing the 



ECZEMA. 263 

subsequent evolution of the malady, and pronounce that to be an 
eczema which fails to respond promptly to treatment; and that, a 
dermatitis which is capable of speedy relief. The climax of such 
absurdity is reached when they are shown obstinate cases of eczema 
of artificial origin, and the response is, that the induced dermatitis 
gave rise to an eczema in a predisposed subject. 

One step further and we are in position to estimate the approxi- 
mate value of the etiological factors in eczema. The large majority 
of all generally recognized and externally operating causes of the 
complaint, fail to have such an effect in the mass of individuals. 
Whether any one of them be necessarily followed by the disease is 
open to some question. Even the poison ivy, a fertile source of the 
disorder in susceptible individuals, will fail to influence others. 
The late and eminent Professor Boeck, of Christiania, when he last 
visited America rubbed the tender leaves of this plant over his hands 
and face in repeated efforts to produce the disease in his own person, 
and utterly failed of the desired end. 

Respecting the numerous agencies operating thus externally and 
capable of producing the disease under consideration, it is to be re- 
marked that they can all be referred to either : solar light and heat ; 
contact with foreign bodies in various vaporous, fluid, or solid states ; 
toxic agencies of a widely differing nature ; traumatisms in varying 
degrees ; and the action of parasites. Many of these cooperate ; some 
include others ; and some become effective by aggravating a disease 
which others have engendered. The reader is referred to the chapter 
on general etiology for fuller consideration of this subject. It will 
be sufficient to note here that acids, alkalies, antimonial and mercu- 
rial compounds, mustard, sulphur, castor oil, capsicum, arnica, tur- 
pentine, chloroform, ether, alcohol, and a long list of other medica- 
ments are capable of producing eczema when applied to the skin 
externally. The same is true of articles manipulated in many of the 
trades — those, for example, handled by the grocer, the baker, the 
confectioner, the seamstress, the ink-manufacturer, the mason, the 
cook, the gardener, the laundress, the painter, the dyer, the printer, 
the tobacconist, and the chemist. Then, too, the eczema of the person 
exposed to intense cold, or intense solar light and heat, aided by re- 
flection from the water, or even by excessive artificial heat, as the 
fire of a furnace, illustrates the action of other causes named. Pres- 
sure and friction -effects are exhibited in the eczema produced by the 
contacts with gaiters, cuffs, trusses, saddles, crutches, and corsets. 

Scratching is a fruitful cause of eczema when the skin is affected 
with pruritus as a distinct disease, or as a symptom of other cutaneous 
disorders. Thus it is efficient in urticaria, scabies, and the prurigo 
of Hebra; in the skin bitten by lice, insects, bed-bugs, and fleas 
(which even without such interference are capable in many cases of 
inducing the disorder) ; and in the lower extremities, where the skin 
is distended by varicose veins. 

Water is capable of exercising an injurious effect upon the skin to 
the extent of producing an eczema, whether it proceeds from the 



264 DISEASES OF THE SKIN. 

sudoriparous glands in au excessive exudation of sweat which is not 
duly removed by ablution, or be applied externally as a fluid in ex- 
cessively cold or hot temperatures, or in the vapors of the popular 
Turkish and Russian baths, or yet again be rendered irritating by its 
saline or other constituents. 

The exterual sources of eczematous trouble named above should 
be regarded simply as suggestive illustrations. It should be borne 
in mind that every contact with the external world, sufficiently severe 
or prolonged to awaken the resentment of the healthy skin, may be 
followed by the protest of the latter in the shape of an eczema ; and 
the same may be true when even the most trivial external accidents 
occur to the sensitive skin of certain individuals particularly prone 
to the disease. 

Pathology. — The pathological changes in eczema are those of in- 
flammation of the skin, varying somewhat with the acuteuess or 
chronicity of the process, and the character and career of the exudate 
furnished in each expression of the disease. In all cases there is, 
first, a circumscribed or diffused hyperemia of the affected part. 
This results from a series of more or less rhythmical and alternate 
dilatations and contractions of the vascular capillaries, the apogee of 
which is persistent vascular distention, blood-stasis, and the condition 
generally recognized as engorgement of the affected parts. This 
engorgement becomes visible to the eye in various shades of increased 
redness. Then occurs an exudation, by which a material in various 
degrees of fluid or solid consistency is added to the tissues. This 
process is also coarsely appreciable, either by the free ooze of serum 
from the surface, or by the imprisonment of such exuded fluid in the 
chambers of the vesicles which it produces, or by an increased 
thickening of the various constituents of the skin, perceptible when 
these are pinched up between the finger and thumb, or, lastly, by the 
appearance of various solid or semi-solid projections concerning the 
skin proper, 02', secondarily, its glandular appendages, which visibly 
spring from the involved area. Thus are explained the various 
erythematous, vesicular, pustular, and papular manifestations of 
eczema. 

A history of the many doctrines which have been held regarding 
the part played in these phenomena by the bloodvessels, the nerves, 
and the tissues would simply exhibit the several steps which have 
been taken in arriving at the facts now demonstrable. The researches 
of Heitzmaun serve to throw light upon this inflammatory process 
in the skin in a highly satisfactory way. 

As to the part played by the epithelium, Heitzmann 1 shows that 
the initial step of the inflammation is declared by an increase of the 
living matter, both within and between the protoplasmic bodies ; the 
former produces a coarse granulation of the epithelia due to increase 
of living matter. This increase is evidently due to augmented afflux 
of nutritive material in the stage of hyperemia. It is declared at 

1 Transactions Amer. Derm. Association, Fourth Annual Meeting 



ECZEMA. 



265 



the points of intersection of the protoplasmic network (the formerly 
so-called granules) by their enlargement, and by the shining and 
solid condition of that part of the network called the nucleus. The 
increase of living matter between the protoplasmic bodies is declared 
in a thickening of the threads traversing the cement-substance. 
Every particle of the living matter, either within or between the 
epithelia, is capable of producing a new formation of epithelial ele- 
ments. Thus is explained the part played by the epithelium in 
the thickening of the skin, the production of scales in squamous 
eczema, etc. 




Chronic eczema — vertical section of the skin of the forearm, a, epidermis ; 6, thickened rete ; 
c, hyper-pigmented layer of rete ; cl, enlarged papillae ; e, atrophied sebaceous gland ; /, atrophied hair- 
follicle ; g, infiltrated corium. (After Kaposi.) 



In connective tissue, the first manifestation of the inflammatory 
process is the dissolution of the basis-substance, and reappearance of 
the protoplasmic condition ; by this process, and the new formation 
of medullary elements which may start from any particle of living 
matter, the inflammatory infiltration is established. The sum total 
of the inflammatory elements which remain united with each other 
by means of delicate offshoots represents an embryonal or medullary 
tissue. In the case of erythematous eczema, the new formation of 
medullary elements is scanty, and resolution is accomplished by refor- 
mation of the basis-substance. 

In papular eczema the papillae of the skin are enlarged in all 



266 DISEASES OF THE SKIN. 

diameters, partly owing to a dilatation and enlargement of their capil- 
lary bloodvessels, and partly to the peculiar connective-tissue changes 
already described. Plastic formative inflammation may be accom- 
panied by the accumulation of a larger amount of serous or albu- 
minous exudation in the epithelial layer as in vesicular eczema. 

Suppuration in the epithelial layer of the rete mucosum is pro- 
duced by the accumulation of an albuminous or fibrinous exudate, 
in consequence of which a number of epithelia are destroyed, and by 
a new formation of pus corpuscles from the living matter of the 
epithelial elements themselves. Epithelial suppuration of this sort 
is not followed by a cicatrix. This is the pathology of eczema pus- 
tulosum aud eczema madidaus. 

The elevation of the temperature in the inflamed skin is somewhat 
proportioned to the rapidity of the process. In acute eczema, such 
elevation may exceed 105.5° F. (41° C), while in chronic eczema it 
can scarcely be appreciated. 

The fluid exuded iu eczema, whether taking part in tumefaction 
of any portion of the skin, as in vesiculation, or in a free discharge 
from the surface, is always identical. It is a yellowish-white, sticky 
and syrupy liquid, feebly alkaline in its reaction, depositing albumen 
in abundance when treated by heat and nitric acid, and .exhibiting 
the characteristic features of the serum of the blood under the micro- 
scope. Exposed to the air, it desiccates in light yellowish to brownish, 
friable crusts, which resemble honey or gum. 

Increase in the pigment particles distributed to the epithelia of the 
rete is characteristic of the chronic forms of eczema, and more espe- 
cially of those where the circulation is somewhat impeded by the 
influence of gravity, as, for example, in the lower extremities. This 
is true, however, of all diseases accompanied by an augmented afflux 
of blood to any part of the body, as, for example, over the surfaces 
of joints to which for many years stimulating embrocations have been 
applied. 

Diagnosis. — Eczema is such a protean disease in its manifestations, 
and is, moreover, of such frequent occurrence, that it is necessary to 
establish a differential diagnosis between it and a large number of 
other cutaneous disorders. The more important of these are named 
below in alphabetical order for convenience of reference, the distinc- 
tive differences of each being briefly appended. It must be remem- 
bered, however, that the identity and characteristics of eczema are 
made clear only after a close study of all its features ; and that is the 
surest basis for an accurate diagnosis in every case. 

Acne. — Acne occurs chiefly on the face, neck, and back of the 
trunk, and its pustular forms might be mistaken for eczema of the 
same localities. But pustular acne is usually accompanied by a 
deeper-seated infiltration than the similar lesions of eczema; and this 
infiltration is also generally limited to the sebaceous glands or peri- 
glandular tissues. In eczema the itching is often severe, while in 
acne the subjective sensations are those of heat or burning; come- 



ECZEMA. 267 

dones intermingled with the pustules of acne will aid in distinguishing 
the two. 

Erythematous eczema of the face is to be distinguished from Acne 
Rosacea by its more generalized infiltration, its production of itching, 
and its greater diffusion over the face; while acne rosacea is more 
often limited to the cheeks, nose, brow, and the regions adjacent to 
these parts. The patch of erythematous eczema is " hot ;" that of 
acne rosacea "cold" to the touch. The former is seen in infancy; 
the latter is rare in that period of life. Acne rosacea is also in many 
cases readily distinguished by the development of visible bloodvessels 
in the skin of the cheeks or nasal region. Lastly, in erythematous 
eczema, the lids are apt to suffer, while in acne rosacea this is the 
exception. In severe forms of acne the sub-epidermic pus formation 
and the resulting scar will prove significant. 

Dermatitis. — Dermatitis, of artificial origin, is to be distinguished 
from idiopathic eczema rather by its history than by special differ- 
ences in the appearance or evolution of lesions. In many cases the 
two affections are indistinguishable. A history of traumatism or of 
the external application of irritant or toxic articles will often serve 
to distinguish the two. Dermatitis of artificial production is usually 
sudden in its onset, the date of which will nearly correspond with 
the time of the operation of the exciting cause. The subsidence of 
the symptoms after the withdrawal of the cause will also point to the 
nature of the affection. Eczema is also much more capricious in its 
distribution and career. 

Erysipelas. — Erysipelas is generally accompanied by febrile 
symptoms, and in many cases by bullpe. The affected surface is red- 
dened, much more swollen than in eczema, and exhibits besides a 
characteristic shining appearance, which is always absent in erythema- 
tous eczema. The line of demarcation between the affected and un- 
affected portions of the skin is usually distinctly defined in erysipelas, 
ill defined in eczema. Erysipelas spreads from one point to another 
with a rapidity which is never noticed in eczema, the latter disease, 
moreover, exhibiting under a glass its minute papules or vesicles. In 
eczema also, when occurring upon the face in the erythematous form, 
the scalp is usually spared, while erysipelas tends to invade the scalp 
and the regions covered by the beard. 

Erythema. — Eczema is to be distinguished from the forms of 
erythema which are due to hyperemia only, by the presence of an 
inflammatory process. The erythema simplex which advances to 
exudation, at once transgresses the artificial line of distinction between 
the purely congestive and purely exudative disorders. It must there- 
fore be remembered that many eczemas begin as erythemata, and that, 
clinically, the latter may represent but a stage in the disease process. 
The discharge in erythema intertrigo results from imprisoned or 
chemically altered sweat, and will not stiffen linen, as does the serous 



268 DISEASES OF THE SKIN. 

exudation of vesicular eczema, for example. Erythema multiforme, 
an affection really on the border-line between the two pathological 
classes here sought to be distinguished, will be recognized by the 
absence of severe itching, and the recurrence of the disorder at certain 
special seasons of the year; while E. papulosum, E. tuberosum, and 
E. nodosum, display solid elevations of the surface much exceeding 
in size the minute lesions of papular eczema. 

HERPES. — Eczema is, in the minds of many, so associated with the 
occurrence of a vesicle, that other vesicular disorders are apt to be 
confounded with it. But in herpes febrilis the vesicles are usually 
grouped about the mucous outlets of the body, and when actually 
under observation exceed in size the minute and transitory lesions 
of vesicular eczema. In herpes zoster with the limitation of the 
eruption to one side of the body, there is also a history of precedent 
neuralgic pain. The subjective sensation is a decided burning rather 
than itching, and there is a possibility of the subsequent production 
of scars. 

Impetigo and Impetigo Contagiosa. — In these forms of disease 
the pustular lesions are usually isolated, do not spring from an in- 
filtrated surface where other lesions may be visible, and are unaccom- 
panied by the intense pruritus which is characteristic of eczema. The 
pustules, moreover, are larger, and the resulting crusts, as a rule, 
bulkier and darker colored than in eczema. Again, in pustular 
eczema the cutaneous affection usually occurs in one or more patches, 
while in impetigo a dozen or more isolated pustules may be irregularly 
scattered upon the entire surface of the body. In the contagious form 
of impetigo, there may be a history of the extension of the disease 
from one member of a family to another. 

Lichen Planus. — In this disorder the papules never become 
vesicular as in eczema ; while those of the last-named disease never 
assume in any stage the peculiar sepia-tinted hue of the similar lesions 
of lichen planus. The latter, moreover, are often umbilicated, are 
chronic in development, frequently symmetrical in disposition, and 
are scaly at the flattened summit. 

Lichen Ruber. — Here the dull red, non-excoriated papules, 
covered with minute scales, unattended by severe itching, could 
scarcely be mistaken for the vivid, angry, and scratched papules of 
eczema, which, moreover, are often accompanied by secretion from 
the surface. AVhen the scales covering patches of coalesced papules 
in lichen ruber are removed, the orifices of dilated hair- follicles become 
visible. This is never true of papular eczema. But the important 
symptoms of a grave disease in lichen ruber, such as marasmus and 
the indications of a fatal termination, will not fail to attract attention. 



ECZEMA. 269 

Lupus Erythematosus. — Lupus erythematosus greatly resembles 
certain forms of squamous eczema. The greater chromcity of lupus; 
the firm attachment of the scales; the symmetrical distribution of 
certain patches upon the face; the association of the disease with the 
sebaceous glands; the definite border of each involved area; and, 
above all, the discovery of the cicatrix where it has existed, will 
sufficiently distinguish the disorder. In eczema there is usually itching, 
often vesiculation, more rapid extension of the borders of a single 
patch, and scales much more loosely attached, than in erythematous 
lupus, which are never provided as in the latter disease with stalacti- 
tiform plugs on the inferior surface. 

Lupus Vulgaris. — Lupus vulgaris is readily distinguished from 
eczema by its more chronic career, its larger papules and tubercles of 
dark reddish-brown hue, and by every one of its destructive pro- 
cesses, none of which is ever recognized in eczema. 

Pediculosis. — As eczema is often induced by lice upon the head, 
pubes, or clothing, it is always necessary to exclude the operation of 
such causes both for diagnostic and therapeutic purposes. Eczema, 
limited to the pubic region or existing there, and elsewhere only 
about the axillae, should suggest careful examination of the skin and 
hairs for the discovery of the crab louse. As for the pediculus 
corporis, it should be the rule of the physician, invariable and 
never to be forgotten (whatever the social position or refinement of his 
patient), to search for evidence of the parasite upon the under surface 
of the clothing worn next to the skin, at the instant of its removal 
and while the patient supposes him to be busied with the inspection 
of the cutaneous lesions. The excoriations produced by scratching 
wounds inflicted by body lice are usually out of all proportion to the 
amount of skin disease present ; and this is the most significant of all 
symptoms next to the discovery of the corpus delicti. Head lice may 
precede or follow eczema of the scalp, but either they or their ova 
(nits), clinging in numbers to the hairs, will be visible to him who 
looks carefully for them. 

Pemphigus and Pityriasis Rubra. — The large isolated bullae 
of pemphigus vulgaris are never seen in eczema. In pemphigus 
foliaceus the lesions are succeeded by the formation of pastry-like 
crusts, scaly exudation, superficial soreness, and the eventual produc- 
tion of an extensive and usually fatal exfoliative dermatitis. The 
marasmus becomes then rapidly conspicuous, while, as a rule, itching 
and infiltration are not present. The disease known as pityriasis 
rubra is equally rare and fatal ; and, though unattended with the 
production of bulla?, is characterized by an equally abundant epidermic 
exfoliation, itching and infiltration being either entirely wanting or of 
insignificance in comparison with the other symptoms present. The 
scales too are papery, large, and thin ; there is no vesiculation and 
moisture, and little, if any, infiltration of the skin. The latter is, 



270 DISEASES OF THE SKIX. 

moreover, of a uniformly reddish hue. Both pemphigus foliaceus 
and pityriasis rubra are particularly liable to be complicated with 
chills or uncontrollable diarrhoea. Without question, many of the 
reported cases of so-called pityriasis rubra are instances of squamous 
eczema. Here the localization of the disease to one or more patches 
upon the body, the severe itching, and the distinct infiltration of the 
patch, will point to the eczematous character of the disease. Observa- 
tion of such patients will finally convince the observer, in many cases, 
that there is occasional weeping from the surface. 

Prurigo and Pruritus. — In the prurigo of Hebra, a disease 
exceedingly rare in this country, there are infiltration, intense itching, 
and numerous minute papules. But the disease usually occurs within 
a year or two after birth, and lasts for a lifetime, extending generally 
over the greater part of the body, sparing only the palms and soles 
(which eczema does not), and is accompanied by inguinal adenopathy. 
In pruritus, often confounded with prurigo, there is itching without 
disease of the skin save that induced by the nails to relieve the sensa- 
tion. Hence, pruritus without scratching will not reveal a cutaneous 
disease; while the same disorder with scratching will exhibit either 
excoriations, or an eczema induced by the attacks made upon the 
skin. The last is, however, rarely noted. The distinction will be 
clear when it is remembered, first, that pruritus is usually of a 
paroxysmal character, worse regularly at certain hours or seasons; 
secoud, that pruritus not originating in a cutaneous lesion, but in- 
directly producing the latter by the medium of the nails, never ex- 
hibits as much cutaneous excoriation as the skin bitten by lice or 
attacked with eczema. The impressive symptoms here are always the 
disproportion between the complaint of the patient and the visible 
symptoms, and the vast preponderance of all lesions, when the skin 
has been scratched, in those regions of the body most accessible to the 
hands, such as the anterior faces of the limbs, the genital region, 
lower belly, etc. 

Psoriasis. — Psoriasis and eczema in typical forms are distinct. 
Variations from type in the direction from one to the other furnish 
many obscure cures. 

The following are the chief diagnostic points in psoriasis : Sharp 
definition of contour of patch; abundance and lustrous hue of scales; 
absence of moisture ; vascularity of tissue beneath the scales ; sites 
of election on posterior aspect of trunk and extensor surfaces of 
limbs; chrouicity in course; uniformity of lesions; and usually 
absence of itching. In eczema : there is an ill-defined contour ; 
usually scanty scales not having a nacreous hue; a preference for the 
flexor surfaces of the extremities, though the disease may occur in 
any portion of the body ; generally, at some period in its course, a 
history of moisture ; polymorphism, as regards lesions ; and a marked 
intensity of subjective sensations. Upon the scalp, psoriasis is partic- 
ularly apt to extend beyond the hairy border in a fillet stretching 



ECZEMA. 271 

across the upper portion of the forehead and thence irregularly down 
in front of the ears ; while eczema of the face, when the scalp is also 
invaded, departs boldly from the hairy parts to the lower limits of 
the forehead, the lips, nose, cheeks, or chin, regions which are rela- 
tively spared by psoriasis. Finally, the two diseases, in doubtful 
cases, will generally be distinguished by carefully searching the 
entire surface of the body, upon some part of which, in psoriasis, 
there will usually be discovered a tell-tale patch of typical appear- 



Scabies. — Scabies is really an artificial eczema induced by the 
incursions of the acarus scabiei, and its lesions are thus those of 
eczema. In scabies, however, the pruritus is intense and the several 
papules, vesicles (these much less closely set than in eczema), and 
pustules are more likely to be coincident than successive, exhibiting 
thus the multiformity characteristic of the disorder when produced 
by the parasite. The discovery of the presence of the latter, especi- 
ally if there be a history of contagion and the localization of the 
disease in its sites of preference, will at once determine the diagnosis. 
Scabies never attacks the scalp. Its sites of preference are, in both 
sexes, the fingers, hands, wrists, and axillae ; in women, the breast 
and the nipple ; in men, the penis ; and, in children, the buttocks. 
The presence of the acarian furrow, if the disease has existed for 
some time, and the appearance of minute blackish dots or points 
upon or about the lesions, usually suffice to establish the real nature 
of the disease. 

Scarlatina. — This disease could only be confounded with 
certain of the varieties of eczema exhibiting an erythematous type. 
Tn scarlet fever, however, the elevation of temperature, the appear- 
ance of the tongue and fauces, and frequently the history of 
contagion, serve to distinguish the disease. The peculiar " boiled 
lobster " appearance of the skin, and its symmetrical distribution 
over the surface of the body, with gradual extension from the head 
and trunk to the lower extremities, are never seen in eczema. The 
finger-nail drawn across the skin of the patient affected with scarlet 
fever is usually followed by the occurrence of a whitish line corre- 
sponding with the impression made with the nail, which is highly 
characteristic of the eruption. Lastly, a generalized eruption of 
eczema will never disappear with the rapidity of the scarlatina rash. 

Seborrhcea. — Seborrhoea and eczema may coexist, either disease 
preceding the other. Typical forms of each are readily distin- 
guished. In eczema there is infiltration and much consequent 
itching ; in seborrhoea, neither. The scales of seborrhcea are more 
voluminous, greasy, freely shed from the surface, and seated usually 
upon an integument of scarcely altered hue. In eczema the scales 
are dry, scanty, and more firmly attached to a usually hyperaemic 
base. Seborrhoea of the hairy parts is generally symmetrically 



272 DISEASES OF THE SKIN. 

diffused ; eczema, though occurring with ill-defined contour, is rarely 
as symmetrical, usually more acute, and seldom followed by alopecia. 
Upon the non-hairy portions of the body the same distinctions can be 
to a great extent observed. The crusts of eczema removed from the 
face generally disclose beneath them an oozing surface, while the 
under surface of these crusts never exhibits the stalactite-like pro- 
longations which pass from the under surface of the seborrheic crusts 
into the patulous orifices of the excretory ducts of the sebaceous 
glands. 

SYCOSIS — Both the parasitic and the non-parasitic forms of sycosis 
are limited to the region of the beard, while eczema of the hairy 
portions of the face will usually be found to aifect other regions. In 
eczema the itching is severe, the exudation spreads beyond the limits 
of the beard, and the discharge is characteristic, while in both forms 
of sycosis there is no oozing, and the subjective symptoms are 
trivial. The discovery of the parasite in the root or shaft of the 
hair will at once distinguish the parasitic forms of the disease. In 
sycosis, each pustule is perforated by a hair. Eczema limited to the 
region of the beard is even rarer than the two varieties of sycosis. 
The circumscribed indurations and tuberculations of the affection 
produced by the trichophyton, as well as the loosening of the hairs 
in their follicles, constitute further distinctive differences. 

Syphilis. — There can be no question that several syphilitic 
eruptions resemble certain forms of eczema. In the eruptions due to 
syphilis, however, there is usually a history of infection ; of involve- 
ment of the glands and mucous surfaces ; of ulceration and cicatrices 
in advanced periods ; and, especially in the case of infants with an 
eczema-like eruption, a history of snuffles. It should always be 
remembered that the intense itching of eczema is characteristic of no 
one of the syphilides ; and that the latter are remarkable for their 
tendency to occur with a circular or partially circular outline, and to 
be covered with bulky crusts of an offensive odor. A point partic- 
ularly worthy of note is suggested in the diagnosis of chronic 
eczematous affections. A syphilitic eruption limited for an equal 
period of time to one locality will often ulcerate or exhibit evidences 
of repair by scar tissue, no such lesions occurring in eczema. 

Syphilis of the palms and soles exhibits very distinctly limited 
outlines in the usually circular, circumscribed and deeply infiltrated 
patches present, which are often symmetrical in development, or at 
least situated on both sides of the body, even if more fully developed 
upon one limb. Syphilitic pustules upon the scalp usually rise 
above well-defined ulcers. Syphilitic eruptions encircling the mouth 
in children are less angry-looking and formidable than severe eczema 
of the same region, being often made up of flattened papules, moist 
or scaling, grouped in circles about the lips, with mucous patches at 
the angles. 



ECZEMA. 273 

Tinea Circinata. — In ringworm there should be a history of 
contagion, microscopical discovery of the vegetable parasite, distinct 
contour of all separate patches, absence of marked subjective sensa- 
tions and of discharge. These are not symptoms of eczema. In 
ringworm of the scalp the hairs are usually either brittle or actually 
broken at a short distance from the scalp; the scales are fine, dirty- 
white, and not torn from the surface by the finger-nails. In eczema 
the hairs are unaffected, and their extraction from the follicles is 
accompanied by pain. 

In ringworm of the body the patches are distinctly circular ; more 
scaly or papular at periphery than centre ; and, moreover, yield with 
exceeding promptness to the action of a parasiticide. Occurring 
about the thighs and ano-genital region, the disease may be compli- 
cated by eczema, but the characteristic "festooning" of the advancing 
border of the patch downward along the thigh, or upward over the 
pubes, will suggest a microscopical examination of the scales scraped 
from the surface. 

Tinea Favosa. — The cup-shaped, friable, yellowish crusts of 
favus in the scalp might be mistaken for the crusts of eczema of the 
same part ; but here the exudation is slight ; there are no pustules of 
eczema, and hence no history of discharge. The odor, moreover, is 
characteristic. In case of uncertainty the microscope would indicate 
the parasitic nature of the disorder. 

Tinea Versicolor. — In this disease, also, the microscope will 
reveal, beneath the epidermal plates, the spores and filaments of the 
vegetation which produces the ailment. From eczema it is easily 
distinguished by the absence of infiltration and of any history of 
inflammation, by the very slight subjective sensation it produces ; by 
its peculiar fawn to chocolate-colored, slightly yellowish patches, with 
superficial furfuraceous desquamation, limited often to the anterior 
surface of the trunk, and readily removed by the action of a para- 
siticide. 

Treatment. — It is proposed to describe here the treatment of 
eczema in general, reserving the consideration of the treatment of the 
forms occurring in particular localities of the body to the pages 
which follow, and which are allotted especially to such local mani- 
festations of the disease. 

In acute eczema, as well as iu many of the chronic forms of the 
disease, the first and most important requisite is that which is the 
simplest, and, perhaps, for that reason most commonly overlooked. 
This requisite is the exclusion of all sources of irritation. 

This completely secured, a large number of cases of the disease 
will proceed to a prompt recovery without any other treatment what- 
ever. Failing this, acute become chronic phases of the disease ; or 
there is a history of exacerbation, recurrence, or development of the 
disorder in new and perhaps distant portions of the body, from 

18 



274 DISEASES OF THE SKIN. 

reflex irritation or augmentation of the sensitiveness of the skin to 
other sources of mischief. 

The exclusion of all sources of irritation necessitates, first, the 
withholding of all harmful internal medicaments. The number of 
patients presenting themselves for treatment of this disease, both in 
dispensaries, hospitals, and in private practice, who have aggravated 
their eczema by the medicaments they have swallowed, is incredibly 
large. Men and women, infants and adults, those who have been 
under the charge of physicians, and those who have purchased their 
drugs of the apothecary at the suggestion of the latter or of their 
friends, exhibit patches of acute or chronic eczema, intensely aggra- 
vated by the injudicious use of arsenic, iodide of potassium, bromide 
of potassium, Donovan's solution, and other harmful preparations 
contained in the various "blood-purifying" remedies sold in the 
shops. The practitioner whose patient comes to him after making 
trial of any such remedies, is strongly urged to set aside carefully the 
operation of such mischievous agents, and to watch the eruption care- 
fully, while their effect is vanishing. The result is often marvellous. 

The exclusion of all sources of irritation necessitates, in the second 
place, the avoidance of all injurious external contacts. Only gross 
ignorance or carelessness will overlook the fact that the inflamed 
skin, like the inflamed bone or the inflamed bladder, calls imperatively 
for rest. The prevalent idea is, however, that the patient with an 
inflamed joint retires to his couch or bed, while the patient with an 
eczema, uuless his disease is so formidable as to necessitate temporary 
withdrawal from the pursuits of business or pleasure, belongs always 
to the peripatetic class. He consults a physician, s\vallow T s some 
medicine, anoints his eczematous skin with a salve, and returns to the 
vocation where his complaint was begotten, just as the man with a 
gonorrhoea will occasionally solace himself by embracing the source 
of his affliction. The baker goes to his baking ; the seamstress still 
pushes her weary needle through the dyed fabrics which first injured 
her hands ; the man with an eczema of the thigh walks the street 
with his trowser leg rubbing the affected surface; the nursing mother, 
with an eczema of the infra-mammary region, still suffers the milk, 
chemically altered in the heat of the summer, to flow over the tender 
surface of the breast; or, in the case of her infant affected with 
eczema, stuff's the folds of a coarse diaper, half laundered or yet 
covered with the dejections from the bowels, between its thighs and 
over the anal region. 

Next is involved the exclusion of all topical irritants in the hands 
of either physician or patient, designed to relieve the disorder but 
having a precisely opposite effect. The number and variety of these 
articles are far from being commonly appreciated. Some are useful 
in advanced stages of the disorder, and harmful in its earlier periods. 
These are generally ordered by persons with a limited experience in 
diseases of the skin, and include a long list of stimulating and 
astringent ointments. Some are employed in sheer ignorance of their 
effects, as, for example, crude petroleum, strong acids and alkalies,. 



ECZEMA. 275 

nitrate of silver, turpentine, and concentrated solutions of corrosive 
sublimate, intended to " burn out " the disease. 

Lastly, the exclusion of all sources of irritation necessitates saving 
the involved surface from the excoriations and other traumatisms 
produced by scratching, rubbing, and excessive washing of the eczem- 
atous skin. In the case of adults some restraint is here needed ; in 
the care of infants, this restraint may need to be enforced. 

This is the only proper treatment of eczema. That which is con- 
ducted without regard to this, is unworthy of the name. The methods 
of treatment about to be described in detail, are to be regarded as 
entirely auxiliary to the measures and precautions suggested above. 
If the latter could be perfectly secured in every case, no other treat- 
ment would be required. If the patient protest that he must continue 
his vocation ; the hands of the sugar-baker returning to their accus- 
tomed manipulations ; the feet of the busy pedestrian to the frictions 
incident to his daily locomotion, then let both physician and patient 
distinctly understand the facts of the case. The former advises the 
speediest method of relief; and the latter elects a slower and more 
uncertain course. In doing this he should be made to understand 
that the responsibility is, to that extent, to be borne by himself. What 
competent surgeon consents to be responsible for that fracture in 
which the extremities of the bone are daily subjected to movement 
on the part of the patient ? 

The great importance of rest and freedom from irritation of all 
sorts in eczema is well illustrated by two classes of cases. There is, 
first, the newly born infant, whose sensitive skin responds early to 
its first harsh acquaintance with the outer world, by an explosion of 
eczema. But it is a fact of singular importance that no child is born 
into the world eczematous. If the nervous system were responsible 
for eczema, such a result might occur, for that system is not only 
capable in intra-uterine life of producing club-foot and other deformi- 
ties, but also of influencing skin disorders. The author has reported 
a case of pigmentary moles at birth, and other observers have 
described similar facts where the lesions were distributed exactly in 
the situation of herpes zoster of the trunk, along the lines of the 
intercostal nerves. If the blood were responsible for eczema, the 
foetus surely might display its lesions, as it does those of syphilis. 
Animal poisons, as those of variola and scarlatina, do not spare the 
unborn child. Nor is it exempt from certain diseases of the integu- 
ment which are generally regarded as due solely to tissue changes, 
since newborn infants are occasionally seen affected with ichthyosis 
or sclerema neonatorum. 

Why is the tender skin of the foetus saved from every form of 
eczema, and the tender skin of the infant accessible to all by such 
various approaches ? Will it be responded that the child has begun 
to respire and digest for itself; that it has become suddenly strumous, 
dartrous, rheumic, arthritic, gouty, or herpetic ; that its standard of 
health is impaired ; that it is suffering from assimilative, nutritive or 
nervous debility, or from any one of the other numberless perturba- 



276 DISEASES OF THE SKIN. 

tions to which eczema has been ascribed? For him who can divest 
himself of all prejudice, there can be but a single answer to the 
question. The difference between the child unborn and the child 
born is, as regards eczema, a difference solely of skin protection and 
skin exposure. The former enjoys what Dr. White has aptly termed 
a "prolonged, placid, subaqueous life." Anointed with unguent and 
immersed in its water-bath of grateful temperature, its skiu cannot 
be fretted to produce an eczema. The latter, abruptly and often 
rudely brought into contact with the outer world, may speedily 
exhibit the most formidable symptoms of the disease. 

The second class of cases to which reference is made, exhibit the 
reverse of this picture, and are best observed in hospital practice. 
Attacked with such severe symptoms of the disease as to justify admis- 
sion to these charities, eczematous patients, usually impoverished in 
their resources and often injured by exposure during severe bodily 
toil, rarely fail to improve greatly during the course of a few r days, 
when no treatment of an active sort has been adopted. In the larger 
number of cases, while waiting to study the evolution of the disease, 
one is limited to the observation of its involution. The mere rest in 
bed in a recumbent position, with a proper regulation of the diet and 
exclusion of all sources of irritation, has here been sufficient to secure 
relief. 

If any apology be needed for the space devoted to this part of an 
exceedingly interesting subject, it must be based upon the great fre- 
quency of the disease ; the wide diffusion of erroneous doctrines 
respecting its nature and the method of its management ; and the 
mischief resulting from the too common aggravation of the disease 
in its earliest manifestations. 

The dietary allowed the eczematous patient should be limited to the 
most digestible articles of food, and should exclude those known to 
be capable of exciting cutaneous irritation, a list of which is given 
in the chapter on urticaria. A moderate use of fresh meats, cooked 
vegetables, and fruits may be permitted, but starchy articles in 
excess, hot breads and cakes, pastry, confectionery, cheese, pickles 
and pickled meats, cucumbers, cabbage both raw and cooked, pars- 
nips, turnips, beans, oatmeal, cracked wheat, peas, celery, shell-fish, 
salted fish and meats, pork and veal should be avoided. Milk, 
when not the source of constipation, may be drunk. Coffee, tea, and 
cocoa, are in the doubtful list; as these are positively injurious to 
some patients, and apparently without effect in others. Tobacco 
should always be cut off from male patients suffering from anything 
like a serious eczematous attack. Alcohol in every form is contra- 
indicated save in such conditions as debility or previous habitual use 
in moderation by persons of advanced years. 

Internal treatment. — In the management of acute eczema, cooling 
draughts are useful ; and in all cases occurring in patients who are 
plethoric, who are constipated, or who suffer from other symptoms of 
imperfect excretion, aperients and cathartics are needed. Often a brisk 
mercurial purgative may be ordered at the outset in the form of blue 



ECZEMA. 277 

mass or the compound cathartic pill. The rhubarb and soda mixture 
answers well in some cases. Podophyllin, irisin, and eupatorium may- 
be substituted for these. The saline cathartics, whether employed in 
medicinal formulas, or in natural mineral waters, such as the Hathorn, 
Hunyadi' Janos, or Friedrichshall, are exceedingly useful in the man- 
agement of most cases. The following is a valuable combination 
often advised for cases where both iron and the sulphate of magne- 
sium are indicated : 



R. Magnes. sulphat. 


3ij; 


64 




Acid, sulphur, dil. 


f#j ; 


8 




Ferri sulph. 


9ss; 




66 


Sodii chlorid. 


Sy, 


4 




Cardamom, tinct. comp. 


f3j; 


4 




Aq. dest. 


ad Oss ; 


256 


M. 


Filtra. Sig. A tablespoonful 


before breakfast 


in a tumblerful of 


cool or hot water. 









In some cases of renal derangement, the alkaline diuretics are 
indicated, such as the potassium acetate, carbonate, or citrate, adminis- 
tered with nitre, squills, caffein, or the benzoate of lithium in three 
to five grain (0.26-0.33) doses before meals (Piffard) ; and, in gouty 
cases, colchicum, Vichy water, etc. In patients suffering from acid 
dyspepsia, the liquor potassse, sodium bicarbonate, or ammonium car- 
bonate may be required. 

Aloes and iron, or aloes and ergot are often indicated in special 
cases. The late Dr. Tilbury Fox employed in cases where diuretics 
and alkalies were both indicated, a formula of this kind : 



. Magnes. sulphat. 


3ss; 


16 


Magnes. carbonat. 


3y, 


4 


Colchici. tinct. 


fSss; 


2 


Menth. pip. ol. 


"lij ; 




Aq. dest. 


. flvj ; 


192 



M. 

Two tablespoonfuls in a wineglassful of water every three or 
torn.- hours. 

Cod-liver oil is indicated in all cases of struma and tuberculosis ; 
phosphate of lime in bronchitis ; steel in anaemia and chlorosis. 

In fleshy children affected with eczema capitis, calomel internally 
is a valuable remedy, one to two grains (0.06-0.133) of calomel, 
with two to three (0.13-0.26) of rhubarb rubbed up with five of 
calcined magnesia (0.33) may be given once in the day to an infant; 
or one-twentieth of a grain (0.003) of calomel rubbed up with sugar 
of milk, may be given three times daily, for ten or twelve days. Van 
Harlingen advises small doses of the unspiced syrup of rhubarb, with 
or without magnesia, for the constipation of infants, or from one to 
three drachms (4.-12.), each of powdered rhubarb and the bicarbonate 
of sodium in four ounces (128.) of peppermint Avater, of which a tea- 
spoonful may be administered two or three times daily. Quinine, 
strychnia, the syrup of the iodide of iron, and the wine of iron may 
also be used with advantage when indicated in these little patients. 

Beside the articles enumerated above may be named the following, 



278 DISEASES OF THE SKIN. 

which, after internal administration, have been reported as efficient 
in the hands of various authorities : Calx sulphurata and viola tri- 
coloi (Piffard) ; hyposulphite of sodium, ichthyol, chrysarobin, tar 
(for adults, two drops of purified pix liquida mixed with one-eighth 
part of rectified spirit, gradually increased — Anderson); carbolic acid, 
sulphur, and hydrocotyle Asiatics. 

If the remarks which have preceded are justified by the clinical 
and pathological history of eczema, it follows that there is no con- 
stitutional treatment of the disease, save that which excludes all 
sources of irritation, a point to which attention has been already 
called. Once fully persuaded of this important truth, the physician 
should be capable of managing the complaint without mental bias in 
the direction of futile experimentation with drugs. 

The treatment of the patient, however, may be in one sense re- 
garded as the treatment of his disease, though a very large number 
of eczematous patients are, except as regards the skin, in conditions 
of health. Constitutional treatment, to meet any general conditions 
of ill health, should be, in short, such as is made familiar to the 
physician in his experience as a general practitioner of medicine. 

Mention has been made of but few of the disorders in the long 
list which may coexist with eczema. Some male patients with a 
gleet have an eczema of the thigh, kept up by the discharged secre- 
tion, which calls for treatment calculated in a very indirect manner 
to relieve also the cutaneous disorder. The same may be said of an 
otitis externa ivith a purulent discharge, and of other local and con- 
stitutional ailments which the skilled physician should be competent 
to recognize and treat. Be it clearly understood the while, that all 
such treatment will not relieve an eczema. It simply places the 
patient in the most favorable condition for getting rid of local trouble. 
If one has had the opportunity of observing a large number of 
eczematous patients of every social class treated by internal medica- 
tion of the character approved by those who still cling to a belief in 
the constitutional nature of the disease, he will see that the statements 
here made are based upon a conscientious study of this experience, 
and of the results of personal experiment in the same direction. He 
who desires to build solidly will not lay his corner-stone upon the 
shifting sands, where so many have been disappointed before him. 

Bearing in mind the fact that an eczema will occasionally vanish 
under even the worst mismanagement, the value of arsenic adminis- 
tered internally for its relief should be duly estimated. It is an un- 
certain remedy in all cutaneous diseases ; it is as uncertain in eczema, 
and has unquestionably aggravated as many cases as it has relieved. 
Its value in chronic and persistent forms of the disease is attested by 
men of distinguished reputation ; and upon such authority it may be 
conceded a position among the internal remedies for the malady of 
possible value. It is indeed not as remarkable that a few patients 
annually recover under its administration, as that more do not attain 
the same fortunate end ; for it is the favorite dernier ressort in chronic 
scaling diseases of the skin with physicians of every grade of pro- 



ECZEMA. . 279 

fessional proficiency; and, having in view the large percentage of 
^czeraatous cases with which they are confronted, it is a curiously 
suggestive fact that the position of arsenic in eczema is yet open to 
discussion. If arsenic, which certainly does possess an influence over 
the skin, cannot to-day be demonstrated to have therapeutic value in 
the large proportion of all cases of eczema, what can be said for the 
host of other drugs, too commonly employed for a similar purpose, 
which are inferior to arsenic in their cutaneous effects ? Sunlight, 
fresh air, suitable clothing, and due regime as to pleasure and busi- 
ness — these must be, for many patients, controlled by the physician. 
They do not cure eczema. They may do much to aid in its manage- 
ment; they may do more, if neglected, to furnish sources of its 
aggravation. 

External treatment. — The most soothing applications which can be 
made to the skin affected with acute eczema are, in various propor- 
tions and combinations, water, oil, dusting powders, and occasionally 
ointments. These will be separately considered, but two important 
circumstances must be remembered in their employment — first, that 
an article which will be grateful to the skin of one patient may prove 
irritating to another, the two being to all appearance similarly affected ; 
second, that where the surface is broken, from rupture of vesicles, 
excoriations, abrasions, or fissures, an applied fluid should be of 
greater specific gravity than the serum which is exuded, since other- 
wise endosmosis and exosmosis will occur, and. the surface in conse- 
quence become more tumid and painful. 

Olive or other bland oils may be poured over the surface, applied 
upon folded pieces of lint, or used by inunction. Even these sub- 
stances are at times, however, the sources of irritation. They are 
made more soothing by combination with an equal part of liquor 
calcis, as in the Carron oil, constituted of equal parts of linseed oil 
and lime-water. For the linseed oil it is frequently advantageous to 
substitute cod-liver oil, palm oil, oil of sweet almonds, neat's foot oil, 
olive oil, or lard oil, flavored very slightly with bergamot or lavender 
to correct the disagreeable odor. In combination with equal parts of 
lime-water, one of these may be gently smeared over the surface, while 
a piece of lint, saturated with the same preparation, is also applied. In 
many cases the value of this dressing is greatly enhanced by sur- 
rounding the whole with oiled silk or other impermeable tissue. 

The dusting powders, described in the chapters on General Thera- 
peutics and the Erythemata are available in many cases where the 
surface of the skin is, or is not, broken. These may be composed of 
lycopodium, magnesium, boric acid, bismuth, talc, the oxide of zinc, 
and camphor when an anti-pruritic effect is desired, in combination 
with finely powdered starch. The Anderson powder, the formula for 
which has been already given, is a useful combination of camphor, 
starch, and zinc. In their preparation it is of prime importance that 
they be made perfectly impalpable by sifting them carefully through 
silk bolting-cloth, as they are sources of irritation when they contain 
grain-like particles of untriturated material. The finely bolted 



280 DISEASES OF THE SKIN. 

"Oswego gloss starch," "corn starch farina," and rice flour, sold by 
the grocers, cither singly or in combination with the other articles 
named, are generally accessible, and prepared at hand. It will often 
be of advantage, where exercise in the day is not to be prohibited, to 
employ one of the oily preparations during the night, which can be 
removed in the morning by a weak alkaline bath containing borax 
or the sodic bicarbonate, while the patient employs a dusting-powder 
in the daytime. This can be freely dusted over the surface, as also 
over the soft lint in contact with the eczematous skin, the stocking, 
gloves, or suspensory bag being also well protected by the powder on 
its inner face. 

Water is of value in many cases when properly applied. Excessive 
washing of the eczematous surface is not only disagreeable to the 
patient, but irritating to the inflamed skin. Hot water, applied 
either as a lotion, bath, fomentation, or by sponging, is frequently 
grateful and alleviates the itching. If employed at all, its use should 
be immediately followed, as soon as the part is carefully dried, by 
the other medicament selected for topical application, such as an oily 
or fatty substance, or a dusting-powder. 

Cold water is of service only when it can be continuously applied, 
as its intermittent employment is followed by a vivid reaction in the 
skiu capillaries, whereby the itching is greatly increased. Thus are 
explained many of the nocturnal exacerbations of the disease, notably 
those occurring soon after the patient retires to his or her bed. A 
cold bathing of the part before retiring has been followed by a tem- 
porary calmative effect, the blood being driven from the capillaries 
by the contraction of the tissues. The return of the circulating fluid 
in excess has then been aided by the warmth retained by the bed and 
the bed-clothing. The continuous application of cool or cold water 
requires a constant supply of the fluid from a reservoir of fixed 
temperature, and the exposure to the air of the part to which the 
dressing is applied. Thus evaporation is not checked ; and what is 
intended to be a continuous cold dressing is not transformed into a 
hot fomentation. 

Such fomentations are, however, frequently grateful to the patient's 
skin, and at times fulfil a good purpose. They are applied by dipping 
pieces of soft cloth in hot water, applying them neatly over the 
affected surface, and covering them with oiled silk, rubber cloth, or 
the " protective material" employed in antiseptic surgical dressings. 
Poultices of flaxseed, elm bark, or other bland materials operate in 
a similar manner, but are chiefly useful in softening crusts or other 
morbid concretions upon the surface. When too continuously or too 
frequently employed, they are productive of harm in their macerating 
and relaxing effect upon the skin, whereby its natural tonicity and 
instinct of self-repair (if such a term be permitted) are to a degree 
obtuuded. They are hence but little used in eczema. The combined 
employment of water and fatty substances is an exceedingly valuable 
method of soothing the eczematous skin, but, with the means accessible 
in the private practice of many physicians, can rarely be secured. It 



ECZEMA. 281 

certainly approximates most closely the sebaceous envelope and warm- 
water bath of foetal life. The eczematous skin is first anointed gently 
with a bland unguent, such as mutton tallow, suet, cold cream, or 
vaseline, and is then immersed in a bath of water kept continuously 
at the temperature of the blood. In the case of the lower extremities 
this is accomplished without great difficulty. Less perfect than this 
is the anointing of the surface and the subsequent application of a 
warm fomentation, by strips of soft lint dipped in the water, super- 
imposed with neatness, and subsequently covered with the protective 
gauze. Imbibition of fluids by the skin is prevented by its careful 
anointing ; and, when immersed in the water, the pressure is both 
uniform and gentle. 1 

Medicated water in baths and lotions plays an important part in 
the treatment of acute eczema. The liquor calcis with calomel, half 
a drachm to one drachm (2.-4.), and pure glycerine or mucilage half 
an ounce (16.) to the pint (51 2.) ; the lead and opium wash ; glycerine 
one drachm (4.) to liquor plumbi subacetatis four ounces (128.) ; car- 
bolic acid one drachm (4.), and glycerine two drachms (8.) to one 
pint (51 2.) of camphor or lime water ; a decoction of opium, made 
by boiling five to ten grains (0.33-0.66) of powdered opium in a 
pint (512.) of water, which is strained and rendered demulcent with 
mucilage; sulphate of zinc ten to thirty grains (0.66-2.) to the pint; 
dilute hydrocyanic acid two drachms (8.) to the pint of water ; these 
and similar lotions, the ingredients of which are changed to suit the 
indications of each case, often serve to alleviate the itching, and in that 
proportion to diminish the intensity of the disease. Dr. White, of 
Boston, after bathing the parts for several minutes with the lotio 
nigra, dilute or in full strength, gently smears the surface with a 
small quantity of the oxide of zinc ointment, or, in winter, four 
scruples (5.) of powdered zinc oxide to half an ounce (16.) each of 
cold cream and vaseline. Dr. Taylor, of New York, has suggested 
the following : 



. Liq. plumbi subacetat. 


3ij; 


8 


Opii tinct. 


3\j; 


64 


Camphorse tinct. 


SJ; 


32 


Glycerinse 


IS; 


64 



M. 
Sig. To be mixed with a quart of water and applied on lint. 

To this solution, a greater astringent effect can be given by the 
addition of the subnitrate of bismuth, or oxide of zinc, half an ounce 
(16.) of either to the pint (512.) of the lotion. 

Dr. Duhring, of Philadelphia, has greatly popularized the use of 
the fluid extract of grindelia robusta in the proportion of one part to 
four of water, as a lotion in eczema. Many patients will in this way 
secure relief which they cannot otherwise obtain. 

1 A convenient method of making the applications described above, is by the aid of spongiopiline 
The eczematous surface is first anointed with a bland, neutral unguent, and then covered with a piece 
of spongiopiline, cut to the required size, sewn to a somewhat larger sheet of oiled silk or Lister pro- 
tective, so that the edges may project on every side. The whole is retained in place by a flannel or 
muslin bandage, to which the edges of the impermeable material are attached by stitches. The spongio- 
piline is moistened with pure or medicated water, as desired, of a temperature nearly that of the- 
stomach, and may be re-moistened from time to time. 



282 DISEASES OF THE SKIN. 

Other useful lotions contain finely levigated calamine, one to two 
ounces (3'2.-G4.) to the pint of rose-water, with a small quantity of 
glycerine, and, if the itching he severe, in addition half a drachm (2.) 
to one drachm (4.) of dilute hydrocyanic acid. Boric acid, one to 
two drachms (4.-8.) to the pint of an opiated wash ; thymol, one 
part to one thousand ; and borax or the bicarbonate of sodium in the 
same proportion, containing besides an equal proportion of alcohol, 
spirits of camphor, or chloric ether, is also available. With any of 
these it is proper to moisten frequently the soft lint upon which they 
are applied, and this after ablution with hot, pure or slightly medi- 
cated, water, for the purpose of relieving the itching. 

Van Harlingen uses also poultices made of crumbs of bread mixed 
with ice-cold lead water, where the skin is oedematous. 

From what has preceded, it will be clear that the chief end in the 
treatment of an acute eczema, is the relief of the subjective sensation 
of itching, and the exclusion of all irritants, the two being practically 
one. That which is not grateful to the skin of a patient thus com- 
plaining, had better be, for the time at least, abandoned. So great 
is the difference between different patients as to the toleration by the 
skin of various topical remedies, that it is well, as a rule, at the time 
of the first consultation, to order an alternative treatment, the one to 
be immediately substituted for the other, if such necessity arise. 
Especially is this true in cases where the epidermis is wounded, and 
where the patient can sometimes with comfort to himself exchange a 
dusting powder for a lead wash, or a weak carbolized oil and lime- 
water lotion, while his eczema is tormenting him in different degrees 
at different hours of the day. 

The necessity for this relief is so imperious that at times it over- 
shadows all other symptoms of the disease. He who has never 
studied the case of a man or woman possessed with a furious impulse 
to relieve an intense eczematous pruritus, has not yet completed an 
education in medicine. The fury, for such it really is, has been 
likened to the sexual orgasm, with which it is undoubtedly allied, as 
the two are not rarely coincident when there is severe anal or genital 
itching. The features of the patient are drawn ; he is but half 
conscious of his ejaculations and surroundings ; with his nails or 
other object which he employs he attacks the too vulnerable skin 
with an incalculable savagery. In these exaggerated paroxysms, 
nothing but blood will suffice for his relief. Not till the torn and 
wounded surface oozes with red drops at every point does he emit the 
sighs which indicate that his desire is satisfied. Men and women 
forcibly withheld from doing themselves this severe damage, will at 
times, exhibit muscular spasm, facial expression, and movements of 
the body, scarcely distinguishable from the symptoms of an epileptic 
seizure. This brief outline of a picture familiar to those who have 
had experience of exaggerated cases, will serve to enforce the need of 
the utmost care in selecting a topical remedy in acute eczema, the 
greatest gentleness in its application, and the nicest provision for the 
special needs of each individual patient. 



ECZEMA. 283 

111 proportion as the disease progresses to a subacute or chronic 
stage, the various topical medicaments employed may be changed in 
character so as to produce an astringent or stimulating effect upon 
the part. The utmost skill and prudence, however, are needed at 
this juncture ; and when uncertain as to the proper course, it is well 
to continue the dusting powder, oleated lotion of lime-water, or 
whatever other article may be externally employed. For it is at this 
time that the disorder is readily awakened to renewed activity, a turn 
of affairs which is especially annoying to the patient, and particu- 
larly so to the practitioner if there be a suspicion (truth to say, often 
too well founded) that the aggravation has been due to the treatment. 
It goes without saying, that the routine practice in eczema has long 
been to order an application of the benzoated oxide of zinc ointment, 
irrespective of particular features of the malady in any individual 
case. Now no greater error in this sjjecial direction could be com- 
mitted. The acutely inflamed skin will rarely tolerate the most 
perfectly medicated ointment; and as this acuteness subsides, such 
tolerance is first to be carefully tested, as, for example, by applying 
a weak ointment to a part only of the affected surface. The term 
rarely is, however, here used advisedly. With that singular capri- 
ciousness which distinguishes the eczematous skin of different indi- 
viduals, the zinc ointment occasionally affords very great relief in the 
severest forms of acute vesicular disease. 

In the application of such ointments it should be remembered 
first, that they must be sweet and freshly and carefully prepared ; 
second, that they can be advantageously applied by gently rubbing 
them into the part by the tip of the finger, after which soft lint in 
strips, spread with the same material, may be neatly superimposed ; 
third, that an ointment, if selected, need not necessarily be applied 
to every part of the inflamed skin, since a little pad or circlet of lint 
may be applied only to an oozing or pustular patch ; lastly, that the 
debris of one dressing should be carefully removed before another 
application is made. Strata of any ointment, the older next to the 
skin possibly rancid and having imprisoned beneath them pus or 
other products of the disease, are positive sources of harm. 

The most soothing ointments for use at this stage are the benzoated 
oxide of zinc salve which may be reduced with cold cream one-half or 
more for extremely sensitive conditions of the skin ; Hebra's diachylon 
ointment, described later, of which one part may be combined with 
three or four parts of vaseline or cold cream and from five to ten 
grains (0.33-0.66) of salicylic acid added to each ounce (32.) of the 
whole; or the oleate of bismuth, prepared according to the formula of 
McCall Anderson given below. 

Appended are a few formulae for ointments useful in this stage of 
the disease : 



R. Zinci oxid. 3ss; 2 
Hydrarg. amnion, chlorid. gr. v-Qss ; 

Camphor, pulv. 3ss-3j ; 2-4 

Ungt. aq. ros. §j ; 32 



33-. 66 

M. 



284 DISEASES OF THE SKIN. 

For the oxide of zinc may be substituted the subnitrate or the 
subcarbonate of bismuth, or from two to four grains (0.133-0.266) of 
the red oxide of mercury, or from four to ten grains (0.266-0.666) 
of the mild chloride, or from ten grains to half a drachm (0.66-2.) of 
the ammonium chloride. The cold cream makes an agreeable basis for 
these ointments, though lard, simple cerate, lanoline, vaseline, or 
equal parts of vaseline and the other preparations answer a good pur- 
pose. The cerates are made sufficiently soft for gentle manipulation 
by adding a drachm (4.) or two of glycerine to each ounce (32.) of 
ointment, and may be flavored with lavender, rosemary, or bergamot 
to suit the taste. 

The oleate of bismuth or zinc is prepared by rubbing up one 
drachm (4.) of the oxide of either metal with eight (32.) drachms of 
oleic acid, which is then allowed to stand for two hours. It is after- 
ward heated in a water bath, when ten drachms (40.) of vaseline and 
three (12.) of Max are dissolved in it, the whole to be stirred until 
cold. It is especially useful in the papular forms of eczema. 

The well-known diachylon ointment of Hebra occupies a foremost 
place in all lists of articles useful at this period of the disease, and 
even later. It is prepared as follows : 

Fourteen ounces of the best olive oil are added to two pounds of 
water, and heated to boiling in the water bath. Three ounces and 
six drachms of an equally good article of litharge are dusted over 
the fluid in ebullition, which is constantly stirred throughout, in 
order to prevent the formation of fatty acids. During the cooking, 
water is occasionally added as required. The stirring is to be con- 
tinued till the ointment is quite cold. 

Duhring has lately modified this ointment as follows: 

One part of freshly precipitated (from acetate of lead) pure white 
hydro-oxide of lead is rubbed down with two parts of water, and 
well mixed with six parts of the best Lucca olive oil. Stir the mix- 
ture for about two hours over a hot-water bath near the boiling 
point, and then cool with constant stirring until the proper consistence 
is obtained, and while the mass is cooling add one drachm of the 
oil of lavender to each half pound of ointment. The preparation, 
according to Eisner, a Philadelphia chemist, is said to contain the 
oleo-stearate of lead. 

When properly prepared this ointment is perfectly homogeneous, 
of a light yellowish color, and of the consistency of butter. It has 
been modified by Piffard, and after him by Kaposi, in combining equal 
parts of lead plaster and vaseline. It is commonly flavored with the 
oil of lavender. It is technically known as the uuguentum diachyli 
albi of Hebra. It may be imitated fairly well by melting together 
two or three parts of olive oil, and four of diachylon plaster, stirring 
till cool. 

This valuable ointment, though useful often in full strength and 
even to the exclusion of all others, is yet with such others often com- 
bined with manifest advantage. Thus a drachm or two (4.-8.) of it 
may be added to the ounce (32.) of lard, cold cream, or cerate, with 



ECZEMA. 285 

or without the addition of another drachm or two (4.-8.) of the 
oxide of zinc ointment, or even one of the tarry preparations to be 
mentioned later. 

For the management of acute eczema many rely to-day upon the 
salve niuslins, glycerolates, pastes, etc., which are fully described in 
the chapter on General Therapeutics. Unna's paste is prepared by 
mixing one ounce (32.) of zinc oxide with two ounces (64.) each of 
glycerine and mucilage. To it one per cent, of carbolic acid or sali- 
cylic acid may be added, and the mixture then applied with a brush. 
Veiel recommends as a mull for the face and genitals 



R. Emplast. plumb, simpl. 
Sebi benzoinati 



3ijss ; 10 



Adip. benzoinat. 3ss • 2| M. 

[To make benzoinated sebum : 

R. Seb. taurin. Sijss; 101 

Benzoes. subtil, pulv. grs. xv; l| M. 

Digere in balneo vapor, per horas duas et cola. 

To make benzoinated lard : 

R. Adipis 3ijss; 101 

Benzoes subtil, pulv. grs. xv; l| M. 

Digere in balneo vapor, et cola.] 

With these may be named the glycerole of starch, cucumber oint- 
ment, the emulsion of sweet almonds, the decoction of Irish moss, and 
the salicylated paste made by combining half an ounce (16.) of vase- 
line or lanoliue with two drachms (8.) each of zinc oxide and starch, 
and ten grains (0.66) of salicylic acid. 

In chronic eczema it is necessary at first to remove from the sur- 
face all dried products of the inflammatory process which usually 
remain upon the surface, such as crusts, scales, and masses of effete 
epidermis. For this purpose oil is to be freely used, and care should 
be taken that it is rubbed gently into every part of the affected patch. 
A species of oil poultice may also be applied by saturating pieces of 
flannel or layers of antiseptic cotton with either cod-liver or olive 
oil, and covering these with protective silk gauze and a light bandage. 
As soon as the inflammatory products are softened they are removed 
by washing with soap and water, using for this purpose either the 
ordinary toilet soap, or, where the skin will permit, the spirit of 
green soap, described in the chapter on General Therapeutics. 

The Sarg glycerine soap is an admirable substitute for these articles 
when the skin is tender, and where an elegant toilet preparation can 
be ordered. The crusts and scales once removed, subsequent topical 
application may be made as required in each case. 

The acuteness of the disease having fairly subsided, not only as 
regards the question of time, but more especially as concerns the 
question of what the skin will tolerate, the tarry and allied prepara- 
tions become for the first time worthy of consideration. Valuable 
indeed when such toleration has become experimentally established, 



286 DISEASES OF THE SKIN. 

they arc source- of positive injury when the acuteness of the inflam- 
matory process lias not completely subsided. 

The articles of this class most commonly employed are pix liquids 
(pine tar), oleum rusci (the oil of white birch), oleum cadi num, and 
terebinthina Canadensis (the balsam of fir). The oil of cade, as 
found in most of the shops, is inferior to the oleum rusci, which is 
certainly the better of the two articles. They arc best applied in the 
form of ointments, but are occasionally painted over the surface with 
a camcl's-hair brush in a liquid state. From one-half to two drachms 
(2.-8.) of the tar, in combination with a suitable quantity of the sub- 
carbonate of potash, arc sufficient to add to a single ounce (32.) of 
ointment, the proportions suggested being varied to suit the require- 
ments of each ease. In attempting to meet such requirements, it may 
occasionally be found useful to combine with these ointments the 
oxide of zinc, the mercurial compounds, or the diachylon ointment 
of Hebra, already described. 

The following formulae are illustrations merely of the manner of 
compounding these articles : 



R. 01. rusci (vel. cadini) 


Jss-3jss ; 


1-6 


Potass, subcarbonat. 


9j-3ss; 


.G6-2 


Unguent, aq. ros. 


sj; 


32 


Ft. ungt. 







M. 

For the potassic subcarbonate one-half to one drachm (2.-4.) of 
the zinc oxide may be substituted, or from two to four grains 
(0.133-0.266) of the red oxide of mercury, or yet half a scruple 
(0.666) of the mild chloride. The vehicle also of such ointments 
may be vaseline, lanoline, simple cerate, or half an ounce (16.) of 
either in combination with an equal quantity of diachylon ointment. 

Of the fluid preparations may be mentioned alcoholic solutions of 
tar, half an ounce (16.) of the latter to the pint (512.) of alcohol; 
and in cases where the detersive action of soap is also needed, the 
sapo viridis may be added as follows : 



R. Picis liquidse 


f 3j-ij ; 


H2-64 


Sapon. virid. 


f^jss-iij ; 


48-96 


Glycerin. 


flj; 


32 


Spts. vin. recti f. 


i.5v"i ; 


256 


01. rosraarin. 


f3ss ; 


2 



M. 

Sig. To be rubbed gently into the skin with a flannel rag. 

Dr. Bulkley, of New York, has devised an alkaline solution of 
tar and caustic potassa, which is especially serviceable, as it is mis- 
cible with water in all proportions. It is constituted as follows : 

R. Picis liquid* f,$ij ; 64 

Potassae causticae 3j ; 32 

Aq. destillat gv; 160 M. 

Dissolve the potash in the water, and add slowly to the tar in a 
mortar with friction. 

Sig. '' Liquor picis alkalinus." To be used diluted as a lotion. 

A drachm (4.) or more of this solution may be added to a pint 
(512.) of water; and, as an ointment, the same quantity to the ounce 



R. 


Picis liquid, (vel. ol. 


rusci) 


giv; 


128 




Adipis 




£; 


32 




01. olivse 




3 ss ; 


16 


Misce et adde 










Terebinth. Canadens. 


1 


. 






Sulphur, flor 


aa S3 5 


32 


Si2 


. To be applied three times 


daily with 


i soft brush 



ECZEMA. 287 

(32.) of cold cream, lanoline, or vaseline. It should be remembered, 
however, that the caustic alkali renders it exceedingly irritating to a 
sensitive skin, and it should be employed with caution upon any un- 
tested surface. 

The formula recommended by Spender and described in the chapter 
on General Therapeutics, is a useful means of testing the efficacy 
of tar upon an eczematous surface. When fluid or semi-fluid com- 
pounds of tar are needed upon the scalp, a drachm (4.) of the article 
selected may be rubbed up with an equal quantity of glycerine, and 
added to six ounces of Cologne water (192.). 

Hebra disclaimed any special value for sulphur in eczemas uncom- 
plicated by the acarus scabiei, but in Wilkinson's and other oint- 
ments, it has certainly served a good purpose. The following formula 
supplies an ointment rather less severe, which has practical efficacy 
in chronic eczema : 



M. 



To this may be added the green soap, if a stronger effect is de- 
sired. 

Olive or cod-liver oil may be rubbed into the eczematous skin, 
after combination with equal parts of one of the tarry preparations \ 
and carbolic acid in lotion and ointment, with the balsam of Peru, 
though less effective, answers well in many cases. 

Ichthyol, in ointments of the strength of ten per cent, and less, is 
useful in localized patches of the disease, especially of the papular 
and scaling varieties. The ammonium sulpho-ichthyol is preferable 
to the natrium compound. Its influence upon the skin seems to 
resemble both that of the tars and of chrysarobin, and cannot be 
regarded as greatly, if at all, superior to these agents. 

Whichever article be selected, it should be thoroughly rubbed into 
the affected surface several times in the day, after a small portion of 
the skin has been attacked to test its susceptibility. Should the 
redness, itching, secretion, and infiltration be aggravated by such 
application, it will be needful, for a time at least, to exchange the 
local treatment for one less stimulating. Should, however, the tarry 
or other similar application be well borne, it should be reapplied till 
it is no longer washed away by the ooze fronl the skin. Sometimes 
it is well to permit the former to accumulate till it is naturally shed 
from the surface by exfoliation, a course which will be indicated by 
the absence of all local distress. The new epidermis which forms 
beneath such a coating, should be for a time protected by a dusting 
powder. Occasioning no further subjective sensation, it speedily 
loses its redness and assumes a normal appearance. 

In other cases, indicated by local distress and exaggerated secretion, 



288 DISEASES OF THE SKIN. 

it will be found useful to remove the tarry application completely. 
After saturating it for a few hours with oil, the surface may be 
cleansed with a weak alkaline lotion, and the tar compound then 
reapplied to the oozing skin with flannel or a eamel's-hair brush, 
according as recourse is had to an ointment or solution. 

Hebra used to employ in chronic eczema of obstinate kinds a 
remedy which he claimed to be his ultimum refugium, and which 
"cures every case without exception," the concentrated liquor potassre. 
The objections to its use are, however, grave. It produces severe 
pain, and in inexperienced hands it is dangerous. As a consequence, 
this distinguished dermatologist adopted two methods which he re- 
garded as partial substitutes for it. The first was the inunction of 
the body thoroughly and firmly with green soap, which was not re- 
moved by washing, but left in contact with the skin for several days, 
while the patient was wrapped in blankets. The second was his well- 
known method of treating more circumscribed patches of chronic 
eczema with soap washing and ointment, the process being described 
below in nearly his own language: 

A piece of green soap, as big as a walnut, is spread upon a flannel 
rag, and rubbed into the eczematous part for several minutes, pressing 
firmly the while, and from time to time dipping it into water in order 
to produce a better lather. The part is then washed free from suds 
with water, carefully dried, and the oil or ointment selected for topical 
use immediately applied on strips of muslin. These ate neatly ban- 
daged to the part. The soap must be rubbed in at least twice every 
day, so long as any excoriated points appear after its application. 
Soap rubbed into the healthy skin will not be followed by such effects, 
the part feeling clean, smooth, and comfortable after it has been 
washed off with water. The contrast this offers to the eczematous 
parts is very striking, the latter presenting numerous intensely red, 
raw, and moist spots. These are all caused by the action of the soap 
in softening and destroying the layer of cuticle which was before 
undermined by the eczematous fluid so as to form coverings for vehi- 
cles. Each, therefore, represents the floor of a vesicle, the roof being 
removed. The appearance of these red, shining, moist points after 
the first inunction suggests to the inexperienced eye that the malady 
has been aggravated; but they become fewer in number after each 
application, and finally entirely disappear, the eczematous surface 
being then no more affected by the soft soap than is the surrounding 
healthy skin. 

For the production of marked effect upon different patches of the 
eczematous skin — thos"e, for example, upon the palms and soles 
characterized by callosities, thickening, or even verrucous growths — 
a ten per cent, salicylic acid salve can be used after the shampooing, 
or Unna's salicylated gutta-percha plaster mull. 

Energetic effects are also obtained by the use of naphthol, chrysa- 
robin, and pyrogallol, in the strength of from one part to ten, to 
one part to thirty of salve. It is well to begin with a strength not 
exceeding one to two per cent., and gradually increase. 



ECZEMA. 28*9 

Frazer 1 speaks highly of the application of iodoform to eczematous 
patches. It is employed in the form of an ointment, containing 
from ten to thirty grains (0.66-2.) of powdered iodoform to the ounce 
(32.) of cerate. 

Other stimulating articles have been found useful in the treatment 
of eczema. Among these may be named cautharides, employed as a 
blister, the nitrate of silver in crayon or solution, and iodine in com- 
bination with carbolic acid. The following formula should furnish 
a^clear vinous-red fluid, which may be applied pure or in dilution : 

R. Iodin. tinct. 3ss; 21 

Acid, carbolic, (cryst.) 3j ; 4 

Glycerin. 

Alcoholis aa 3ij ; 8j 

Aq. destillat. ad f|j ; 32j M. 

Sig. Iodized solution of carbolic acid. 

In cases where there is considerable pruritus, especially in obstinate 
patches of papular eczema, the iodized phenol of Bellamy may be 
substituted for this. The formula is : 

R. Iodinii cryst. } . A 

Acid, carbol. j aa 6 ] ' 4 | 

Combine with gentle heat and add an equal part of glycerine. 
Sig. Iodized phenol ; to be applied twice daily with a glass rod. 

Balmanno Squire, of London, has suggested a substitute for the 
diachylon ointment, in the glycerole of the subacetate of lead. 
It is certainly a valuable preparation in many cases, but not superior 
to the other ointment named. The " stock" is prepared as follows : 
Take five parts of the acetate of lead, three and one-half of litharge, 
and twenty of glycerine; heat for half an hour in a boiling glycerine 
bath, constantly stirring, aud filter in a gas-oven or other kind of 
heated apartment. From one-half a drachm to two drachms (2.-8.) 
of this stock, added to the ounce (32.) of pure glycerine, are suffi- 
ciently strong for application to the oozing surfaces of eczema 
rubrum. 

Lassar 2 recommends that the part affected should be at first well 
soaked with antiseptic oil, of which a considerable quantity is ab- 
sorbed by the skin. A muslin bandage, soaked in oil, is then ap- 
plied, and covered with oil-silk. The oil may be rendered antiseptic 
by the addition of one to two per cent, of carbolic or salicylic acid, 
or one and one-half per cent, of thymol. Sometimes the carbolic 
acid can only be borne for a short time, as it will of itself produce 
eczema. Rape-seed oil may be used in place of the more expensive 
olive oil ; but drying oils, such as linseed oil, are to be avoided, as 
they may cause inflammation. In chronic eczema, especially in in- 
fants aud in eczema of the face, he recommends an ointment. The 

i British Medical Journal, July 10, 1881, p. 80. 
2 Annal. de Derm, et de Syph., Sept. 1881. 
19 



290 DISEASES OF THE SKIN. 

formula for an ointment which cannot be rubbed off during sleep, in 
eczema of the face, is : 



R. Acid, salicylic. 


3ss; 


2 


/inc. oxid. 


3vj; 


24 


Amyli 


Svj; 


24 


Vaselin. 


oil ; 


64 



M. 

Wyndham Cottle 1 has employed chaulmoogra oil, or gyuocardic 
acid, in a large number of cases of eczema occurring in persons with 
delicate skins, and over such exposed surfaces as the face, hands, and 
anus. In both acute and chronic forms he has employed these sub- 
stances in the form of ointment, in the strength of from fifteen to 
twenty-five grains (1.-1.5) to the ouuce (32.) of vaseline. The oint- 
ment is applied several times in the day, and, if possible, kept in 
contact with the part on rags over which it has been spread. 

Other mercurial preparations than those named above have long 
been in favor for application to localized patches of the disease. 
Among these may be named corrosive sublimate, the ammonio- 
chloride, the iodide and biniodide, the two oxides, and the nitrate. 

Calomel, which is exceedingly useful in the strength of a scruple 
to a drachm (1.-4.) to the ounce (32.) of zinc, lead, or simple ointment, 
can be often advantageously employed also as a powder in full 
strength, or diluted with bismuth or starch. In localized patches of 
papular eczema, where such a dressing can be tolerated, marked re- 
sults follow this dry dusting of calomel over the part, followed by 
alternate superposition of neatly adjusted strips of Maw's surgeon's 
plaster — the whole kept in situ by means of a neat bandage. If the 
itching is alleviated by such a dressing, it can be reapplied for a week 
as soon as it is loosened, when the redness and infiltration will be 
found greatly reduced. 

Other surgical appliances used in the local treatment of eczema 
are Martin's solid rubber bandage, Fox's tubular bandage of rubber, 
and other dressings composed of starch, gutta-percha, and plaster of 
Paris, intended to support the extremities when the integument is 
weakened. None of these are equal to rest in the recumbent posture. 
The most useful purpose subserved by rubber in the treatment of 
cutaneous affections is as an impermeable outer dressing for watery 
and oily applications. Here the mackintosh and silk protective of 
the Lister dressing answer all the indications. 

Prognosis. — The greatest uncertainty attends the prognosis of 
eczema, so far as regards the duration of the disease and the proba- 
bility of the recurrence of a relapse. With respect to the cpuestious 
most frequently asked, those relating to contagion, heredity, and per- 
sistent lesion-relics, naturally a favorable response can be made. 
But the fact remains that some forms of the disease are insignificant, 
some persistent, and some peculiarly liable to relapse from very slight 
provocation. Only after careful weighing of all the conditions ex- 
hibited by the skin and by the other organs of the patient can a 

1 British Medical Journal, June 25, 1881. 



LOCAL VARIETIES OF ECZEMA. 291 

reasonable probability as to the future be estimated. All this is un- 
satisfactory, and must be so. Eczema is truly a curable disease, but 
unfortunately one not only exceedingly common, but one open to 
aggravation by causes well nigh innumerable. Were the physician 
always in position absolutely to insure his patient the exclusion of all 
sources of irritation, the prognosis would be much more satisfactory. 
In hospital patients, where such control is more perfectly attained, 
the results of treatment may be predicted with some confidence. 

In general, it may be said that acute eczema is more readily re- 
lieved by proper treatment than the chronic forms of the disease ; 
that eczema with a discoverable cause is more manageable than one 
whose etiology is obscure ; that eczema of the very young and of the 
very old is at times particularly rebellious ; that the non-discharging 
phases of the disease are rather more persistent than those accom- 
panied by secretion ; that eczema lingering at the mucous outlets of 
the body (auditory canal, nostrils, mouth, nipple, anus, vagina) is 
more obstinate than when it affects the skin of other parts (shoulder, 
neck, lumbar region) ; that eczema with constant aggravation or 
complications (fissure of the hands, varicose veins of the leg, appa- 
ratus for anchylosis of knee) is more stubborn in proportion as those 
complications or aggravations cannot, from the circumstances of each 
case, be set aside ; and, finally, that an eczema which has long existed, 
or repeatedly recurred, as, for example, with every season of extremely 
cold or hot weather, is, after relief, extremely liable to return. 

THE LOCAL VARIETIES OF ECZEMA. 

Eczema of the Scalp. [E. Capitis. E. Capillitii.] 

When the scalp is affected with eczema, the symptoms differ some- 
what, according to the age of the patient. In adults, the erythema- 
tous and squamous varieties of the disease are more common ; in 
infants and children, the pustular. In the former the eruption is 
usually circumscribed and in patches ; in the latter it is more diffused. 
In the same proportion also the former is generally asymmetrically 
and the latter symmetrically developed. 

In infants and children, the pustules rupture early; and their 
contents dry into dirty- whitish, yellowish, or greenish crusts, matting 
together the hairs, serving as foci for dust accumulation and nests for 
lice, superimposed upon a reddish, oozing, pus-covered, or occasionally 
indolent skin, often foul-smelling, and usually complicated by a 
seborrhoea. The so-called " milk-crust " is usually a compound of 
dried pus and altered sebum. The itching is not so intense as in 
some other forms of the disease. Post-cervical, pre-auricular, and 
occipital adenopathy are common, and in strumous children suppura- 
tion of the affected glands may occur, though this is rare. The 
causes of this form of the disease are evidently associated with local 
conditions. The rapidly growing hairs of the scalp are in intimate 
association with the numerous and large sebaceous glands of the same 



292 DISEASES OF THE SKIN. 

part, which unquestionably respond at times to the physiological 
stimulus they feel, by an exudative process. The acne of the young 
man whose beard is growing, illustrates the same fact. Local irri- 
tants arc not often wanting to push the disturbed equilibrium into 
the scale of disease. Dr. White calls attention to the common neglect 
in removing the " pre-natal cap of cheesy material," as well as to the 
rude and unskilful attempts to accomplish the same end. Extremes 
of temperature, friction, excess, neglect, and absence of endeavor to 
wash the scalp, all these contribute to originate or aggravate the dis- 
order. 

The affection when complicated or induced by lice, is more common 
in children than in infancy, doubtless in consequence of the greater 
independence of the former and their gregarious habits. In girls 
with relatively long hair, the ova, or nits, of the parasite are readily 
distinguished, adhering closely to the hairs and accumulated espe- 
cially about the occipital region. The itching is usually more 
annoying than in pustular eczema not thus complicated. 

The erythematous and squamous forms of the disease, rather more 
common in adults, originate frequently in seborrhcea, when scratch- 
ing or irritant applications have been made. The eruption here 
usually occurs in asymmetrical patches, or may be limited to a single 
patch tolerably well-defined in outline, and this often upon one side 
of the scalp, not as in infancy preferring the vertex. Reference is 
made in the chapter on seborrhcea to a form of eczema of the scalp 
occurring in adults where finger-nail sized, circular, oozing or slightly 
crusted patches are generally disseminated over the surface. They 
result, as a rule, from the scratching of an obstinate seborrhcea in 
" nervous" women; and suggest traumatism, in their reddish friable 
crusts, the color being due to exuded blood. 

The diagnosis of these forms of disease has been already considered. 

In the treatment of the eczema of the scalp in infants and children, 
the first indication to be met is the removal of the accumulated crusts. 
When this is harshly accomplished, it becomes a fruitful source of 
further mischief; it is, therefore, necessary to proceed with great 
gentleness, and thus the thorough softening of the crusts is all 
important. For this purpose it is necessary to soak them in oil and 
to retain this substance in intimate contact with the scalp. Olive or 
cod-liver oil may be selected, and, if needful to correct the odor or for 
other purpose, one drachm (4.) of carbolic acid may be added to each 
pint (512.) with two drachms (8.) of the balsam of Peru. A neatly 
fitting skullcap should be then smoothly applied, constructed of the 
Lister protective or flannel, and fastened in place by a light bandage, 
never by elastic rubber bands. After several hours of soaking, the 
crusts should be removed by warm water and spirit of soap washing, 
and the entire process be repeated till the crusts are completely 
detached. In selecting an article for subsequent medication of the 
scalp, it should always be remembered that even infantile eczema will 
proceed to a natural involution if uuirritated. Hence the oleated 
lime-water, or oil of sweet almonds alone, will often answer better 



LOCAL VARIETIES OF ECZEMA. 293 

than an ointment, and, even where there is considerable acuity of the 
inflammatory process, lime-water alone, with possibly a small quantity 
of glycerine added. In other cases the lime-water can be better 
medicated with calomel or the oxide of zinc. At times, also, it is 
well, even when these applications are kept in constant contact with 
the scalp, to order that a small pea-sized mass of one of the ointments 
described above [such as the benzoated oxide of zinc ointment with 
cold cream, or one medicated with a mercurial compound, e. g., 
calomel, twenty grains (1.33); or white precipitate, ten to twenty 
grains (0.66-1.33) ; or the subnitrate of bismuth half a drachm (2.) 
to the ounce (32.)], be applied at the time of the dressing. This is 
to be gently rubbed in the surface with the tip of the finger, and the 
skin afterward protected as before. 

It is rarely needful to cut the hair unless nits be found, though in 
public charities it certainly is a more expeditious method of arriving at 
the end, when a uurse has to dress the heads of several children in a 
single ward. In adults, especially in women, the hair should be 
spared, while the patient is warned that the loss of the growth upon 
the scalp may be considerable. As a sequel of obstiuate seborrhoea 
such an eczema may be succeeded by alopecia ; in the absence of the 
former, the hairs are usually reproduced. It is rarely necessary to 
employ the skullcap in adults, since one can succeed in insuring the 
necessary applications by directing the attention of the patient to the 
necessity of care and thoroughness. 

Lice when present may be destroyed by the application of petro- 
leum. Nits are removed from hairs which it is not desirable to cut, 
after the petroleum dressing, with alcohol or cologne water. 

As the disease in both classes of patients advances to a subacute 
or chronic stage, the treatment may be changed so as to include the 
various stimulating applications already described, such as ointments 
and spirit lotions containing tar, oil of cade, balsam of fir, pyrogallol, 
alcohol, and sulphur. In the case of infants, however, such stimu- 
lating topical remedies are very rarely to be employed. An eczema 
of the scalp which has once entered upon resolution, in an infant or 
child, should be generally soothed and protected. 

Many little patients thus affected are in excellent general health, 
and require no internal medication. Others, however, demand the 
interposition of the wisdom of the physician to protect them from 
the ignorance or folly of those to whose charge they are intrusted. 
Here is not space for a discussion of the pressing questions relating 
to the nutrition of the infant deprived of the breast and starving on 
the " proprietary" diet purchased of a chemist, or an equally vicious 
aliment compounded by lime-water, and imbibed through a tube by 
which it is flavored with India-rubber and the chemically altered 
casein of milk several days old. A word to the wise is sufficient. 
Fresh pure milk, animal broths, cod-liver oil, must not be neglected. 
This concerns the health of the child, and has indirect connection with 
the eczema. A record of one hundred infants dead of artificial foods 



294 DISEASES OF THE SKIN. 

and marasmus in a public Charity of Chicago, includes in the list 
not a single case of eczema. 

Lastly, patients of both classes are to be saved from mercury, 
arsenic, and the iodide of potassium. 

Eczema of the Face. [E. Faciei.] 

Erythematous eczema of the face in adults is projected prominently 
among the varieties of the disease by its uniformity of type. It 
occurs in early and middle life and advanced years; and is a 
particularly intractable ailment. In well-marked cases, the forehead, 
checks, eyelids, and nose of the patient are involved, exhibiting an 
infiltrated, usually dusky-red, often symmetrical patch of disease, the 
affected surface being slightly elevated above the level of the sound 
skin. This surface is uniformly smooth and reddened; occasionally, 
near the root of the nose and about the lower line of the forehead, 
minute, closely set papules are visible. Very slight oozing, especially 
after irritation, may be noticed. At the height of the disease or in 
its involution, exceedingly fine scales form, which are scarcely per- 
ceptibly shed from the surface. The lids, especially the lower lids, 
in advanced years become puffy. The line of demarcation is unusually 
distinct, and rarely invades the scalp-border or the region of the 
beard. Itching is at times intense, the patient complaining of this 
bitterly, and usually preferring to rub the face with the hands or 
pieces of cloth. Sometimes, however, the face is well scratched with 
the nails, and excoriations and blood-crusts disfigure the countenance. 
Patients of intelligence usually describe the itching as paroxysmal, 
and starting at the root of the nose, whence it travels upward over 
the forehead, and laterally to the brows, often in the line of the 
supraorbital nerves. Certainly at the root of the nose, the exudative 
process is of the most marked character. The eruption also is seen in 
asymmetrically disposed patches of various sizes, with islets of sound 
skin between. In resolution of the symmetrical form, this is 
commonly observed. 

Patients thus affected are often those whose faces have been espe- 
cially exposed to irritation, such as locomotive engineers, wheelsmen 
of sea-vessels, mechanics in trades where the hands are soiled with 
irritants and afterward applied to the face, and women spending 
hours of each day over the laundry-tub or the kitchen-stove. In 
each class the operation of the cause is made manifest by the exacerb- 
ation of the disease after exposure. 

The affection is most commonly mistaken for erysipelas, a disorder 
from which it is readily differentiated by the chronicity of its course. 
The latter feature is particularly characteristic of this form of eczema. 
It is rarely completely relieved after the age of sixty within a twelve- 
mouth ; and, when it has existed for a long period of time, is partic- 
ularly obstinate under the best treatment, recurring with exasperating 
frequency upon exposure of the face to atmospheric changes. The 
great vascularity, abundant supply of sensory nerves, and necessary 



LOCAL VAKIETIES OF ECZEMA. 295 

exposure of the face, probably explain this peculiarity. In its treat- 
ment the dusting powders fulfil an important part. Soothing appli- 
cations should always be first employed. The more stimulating 
applications may be tried later. 

In patients of younger years the face is apt to display vesicular 
and pustular phases of the disease, forms more often of acute eczema, 
and correspondingly more manageable. The itching, and especially 
burning sensations, are apt to be severe ; crusts form rapidly ; and in 
infants the picture presented is often that seen in the scalp, except 
that the hairs are not matted into the crusts ; and there is often a 
reddish blush at the edge of the crust ; or, when the latter has been 
removed, a redness of the oozing surface somewhat more marked 
than the similar patches on the less vascular scalp. The scratching 
in these little patients is severe ; crusts are torn off in part or wholly ; 
blood-crusted excoriations are common. The area of surface involved 
is in this way clearly extended ; sleep is greatly disturbed ; and the 
irritability and fretfulness of the child, thus produced, bear heavily 
upon its general nutrition. In severe cases of long standing the 
mental tone of the little sufferers becomes singularly perverted, and 
the character unquestionably changed. They will occasionally, when 
permitted, pick off and devour the crusts with voracity, and undergo 
nervous crises which are but a step removed from convulsions, and 
doubtless allied to the petit mal of the epileptic. 1 

This chain of formidable symptoms, well linked together, will often 
bid defiance to the most skilled efforts to impart ease to the tormented 
skin. In such cases the harness employed by Dr. White, of Boston, 
fills an important office. The skullcap, described above, and made 
of firm old cotton or linen cloth, is closely fitted to the calvarium, 
and a mask of the same material is shaped to the face with exactly 
placed apertures for the eyes, nose, mouth, and ears. It is gathered 
in beneath the chin, and laps over two inches at the back of the head. 
This may be used only during sleep, or in aggravated cases, also during 
the hours of wakefulness. A species of strait-jacket is made by 
passing the head of the child through a hole in the closed end of a 
small pillow-case, which is then drawn down over the body and 
arms, and the latter confined at the sides by stitching the case together 
between the trunk and the upper extremities, or accomplishing the 
same end with safety-pins. The jacket is finally secured by similar 
means between the thighs. When it is necessary to imprison the 
lower extremities, these are similarly secured by pins within the case; 
and the outer edge of such trousers can be fastened to the bed or 
cushion on which the child reclines. Of course this treatment does 
not preclude the employment of the washes, ointments, etc., which 
are to be neatly applied next to the skin beneath the " trousers " or 
"jacket." The result is that rest is given to the tormented skin, 

1 Among the criticisms elicited by the appearance of the first edition of this treatise, it was charged 
that the picture given iti this paragraph is exaggerated. The experience of the critic, however had 
been too narrow. The accuracy of the description given above has been more than once confirmed in 
the observation of the author since these lines were first written, and they are left standing to-day as a 
hint of the truth. 



296 DISEASES OF THE SKIN. 

which is not suffered to be exposed to a single .scratching even during 
the dressing of the parts; and its natural tendency to repair soon 
brightens up the case. 

In the treatment of these cases, the black wash and zinc salve 
treatment will be found valuable, as also the diachylon salve, lead 
lotions, and the glycerole of starch. Van Harlingen gives the 
following : 



R. Pulv. zinc. oxid. 


3j; 


4 I 


Sevi purificat. 


3ij; 


8 


Adipis 


3iv; 


16 


Pulv. ulmi flaw 


4. s.; 





M. 

To protect the face from the cold air he also employs half an ounce 
(16.) each of glycerine and gum tragacanth, half a drachm (2.) of 
borax, and water sufficient to make a paste. 

In obstinate cases tar should be employed. It is well to remember 
in the management of any case, that while a tarry application may be 
well tolerated over one part, as, for example, on the cheeks and near 
the nose, in another, as, for example, over the lids, a zinc salve may 
be better employed in the same individual. 

Eczema of the Lips. [E. Labiorum.] 

Reference has been already made to the obstinacy of eczema occurring 
near the mucous outlets of the body, a result due, probably, to the 
secretion furnished by the adjacent mucous tracts. The lips furnish 
an illustration alike of this pertinacity and aggravation. Their 
frequent motions in mastication and articulation aggravate an eczema, 
which is, moreover, apt to be teased by a no less frequent thrusting 
of the tongue out of the mouth, where there is no beard, to wet the 
parts with mucus and saliva. One or both lips may be involved, 
vesicular, pustular, squamous, and erythematous lesions occurring at 
one point, or along the entire line of either, with frequently resulting 
crusts and fissures. The vermilion border of the lips commonly 
participates in the process. The lips become hot, sometimes much 
thickened by the swelling and infiltration, their mucous faces being 
rarely implicated. Scarlet, dull red, and other peculiarly purplish 
hues of the vermilion border become visible. The parts are more 
picked than scratched, though the itching is at times severe. The 
pustular and vesicular forms are more common in children. The 
erythematous form, its reddened outline roughened by scales, evenly 
projected beyond the vermilion border, is rather an affection of 
maturer years. In young children the disease is frequently aggra- 
vated by nasal discharges which flow over the lip, giving the latter 
an elephautiasic aspect or even the appearance of an animal's snout, 
a condition noted also in later life. Occurring upon lips covered 
with the hairs of the moustache, the disease exhibits the usual 
symptoms of eczema barbse. In these male patients, the pipe, the 
cigarette, the cigar, and the tobacco chewed and expectorated may 
aggravate the malady. In all cases it is obstinate, and calls for 



LOCAL VARIETIES OF ECZEMA. 297 

either emollient, stimulating, or protective applications. In cases 
displaying acute and painful symptoms, frequent fomentations of the 
part with soft rags dipped in hot mucilaginous and alkaline waters, 
will aid in controlling the swelling and alleviating the pain. In 
chronic cases, where stimulation is demanded, this can be effected at 
the time of dressing, the parts being subsequently protected by collo- 
dion or other material. Carbolic acid and the nitrate of silver are 
often needed for such dressing. In eczema of the hairy lip it is 
often of great service to remove the moustache by shaving. 

Fox suggests the use of thymol, five grains (0.33) to the ounce 
(32.) of cold cream. Van Harliugen applies equal parts of dilute 
phosphoric acid, glycerine, and syrup ; and to the outer edge of the 
lip, two scruples each (2.66) of zinc oxide and honey, six drachms 
(24.) of the oil of sweet almonds, and two drachms (8.) of wax. 
Veiel paints the lips twice daily with soft soap. Taylor's application 
of the tincture of benzoin, each ounce (32.) containing one to two 
grains (0.06-0.13) of corrosive sublimate, is a valuable solution for 
painting over the cracks and fissures near the angles of the lips. 

The diagnosis is between sycosis parasitaria, herpes labialis, and 
epithelioma, the points of difference having been already suggested. 
The first is accompanied by loosening of the hairs, and caused by a 
parasite ; the second is vesicular in lesion, brief in duration, and 
trivial in severity ; the third is a disease of advanced years, rather 
than of early and middle life, and is never accompanied by itching, 
but usually by more or less ulceration. Syphilis is fond of the angles 
of the lips; in most cases when thus limited, typical mucous patches 
of the mouth Can be discovered. 

The lesions of syphilis at the angles of the mouth are seldom 
linear fissures, but more often irregularly outlined erosions, secreting 
a puriform mucus. 

Eczema of the Nostrils [E. Narium] 

is naturally often associated with a chronic coryza. Inasmuch as 
one of the common symptoms of hereditary syphilis is the "snuffles" 
of the child, the physician should carefully exclude the possibility of 
such disorder in every instance when an infant with coryza exhibits 
an "eczema" of the nares or lips. The age of the little patient ; an 
inspection of its anal region (which should never be omitf-ed in infan- 
tile eczema); and the history of the case will throw considerable light 
upon this important question. 

Whether occurring in the adolescent or child, the disease may 
linger only upon the alge in pustular or squamous forms, or block 
up the nares with crusts. In infants this enforces respiration with 
an open mouth, and the grasp of the nipple by the lips is thus inter- 
rupted either by respiratory acts or cries of agitation. The Schnei- 
derian membrane participates in the inflammatory process, and pours 
out its secretion upon the eczematous skin. The membrane when 
inspected is seen to be either raw and succulent, or in a condition 



298 DISEASES OF THE SKIN. 

analogous to that seen in the pharyngitis sicca of" authors, dry, glazed, 
aud free from discharge. The nostrils are often thickened in con- 
sequence of infiltration or fissured, especially at the lines of the nares 
laterally and interiorly. In severe cases, and when the lips partici- 
pate in this process, the pouting, swollen, and distorted organs suggest 
the snoul of the lower animals. Adults as a result frequently suffer 
from non-parasitic sycosis and furunculosis. 

Care should be taken to exclude syphilis in making a diagnosis, 
bearing in mind the fact, that the pustular syphiloderm (which see) 
frequently selects the furrow on either side of the nares for its evolu- 
tion. 

In treating these cases all crusts should be removed, and the parts 
carefully protected. Picking the nose in children should be pre- 
vented if needful, by the "strait-jacket." Pencillings with the com- 
pound tincture of benzoin, iodized phenol, nitrate of silver, and 
collodion will often prove serviceable. In softening crusts, oil may 
be freely used. For this purpose the warm carbolized spray of the 
atomizer answers well, medicated with resorcin which may also 
be efficiently employed for the relief of the nasal catarrh, often 
responsible for the disease in adult cases. Unna recommends drainage 
tubes in such patients, wrapped with lead ointment mull, and, after 
the softening of the crusts, painting every second day with yellow 
precipitate ointment. In the same way a weak citrine ointment or 
white precipitate salve may be used. When the disease extends well 
up the nares, Neumann employs bougies made by combining two 
grains (0.138) of zinc oxide with sixteen (1.06) of cocoa butter. 

Eczema of the Ears. [E. Aurium.J 

The ears are affected with eczema both in infancy and maturer 
years, rather more often in women and children, the disease being 
limited to the whole or part of the organ, or extending backward 
over the post-auricular region, or downward over the ramus of the 
superior maxilla. It may be acute, or chronic, and originate in 
chronic or catarrhal discharges from the external auditory meatus; 
in exposure to temperature changes, especially when aided by high 
winds; in frost-bite; in the irritation set up by pediculi and by 
the auricular limb of the frame of spectacles ; in the toxic effect 
induced by the hook of cheap ear-rings and dyed bonnet ribbons; in 
the traumatism of ear-piercing; and in the habit of unnecessarily 
picking the ear to relieve it of wax or trifling sensations of irritation. 

The pustular and moist forms are common at the superior, inferior, 
and posterior boundaries of the pinna, where a linear fissure is apt to 
form in the line of the angle made by the auricle with the plane of 
the adjacent integument. The motions impressed upon the ear by 
handling it, placing the hat on the head and tying hat strings over 
it, always tend to aggravate the disorder. Long hairs worn over the 
ears may have a similar effect by the production of friction aud the 
retention of heat. The lobules are apt to display the erythematous 



LOCAL VARIETIES OF ECZEMA. 299 

and scaly phases of eczema, becoming infiltrated, having a deformed 
appearance, a lurid red color, and indolent course. The lobules alone 
of both ears in young women may be similarly affected, and exhibit 
these phenomena for consecutive years. Often the chronic inflam- 
mation may lay the foundation for a keloidal growth, an accident 
of several inflammatory processes in other parts. At other times 
the entire auricles present a similar appearance, uniformly dark red, 
infiltrated, alternately weeping and scaling, and projecting to a 
noticeable extent from the side of the head in consequence of their 
increase in bulk. The itching is usually more annoying than severe, 
being accompanied by a characteristic sensation of tenseness and ful- 
ness of the part. Like the eczema which occurs at the other mucous 
outlets of the body, the affection in these parts is particularly obstinate 
when it assumes a chronic form. Symmetry to the extent of involving 
both ears, though commonly to a different degree in each, is rather 
the rule than the exception; and is doubtless due to the simultaneous 
operation of effective causes. 

The diagnosis is between erysipelas, seborrhcea (which occasionally 
occurs in the concha of the auricle), erythema simplex and multi- 
forme, and dermatitis calorica. The mouth should always be care- 
fully examined in these cases for sources of trouble. 

The treatment should be at first soothing and protective by the 
zinc salve or diachylon ointment ; afterward stimulating. A firm 
bandaging of the ears to the head may be required to support the 
parts, to prevent irregular pressure (head upon the pillow), and to 
secure contact with external medicaments. In chronic cases, stimu- 
lant applications are often well tolerated, and the tarry ointments here 
play an important part. Treatment appropriate to the otitis externa 
may be required. Bulkley recommends a tannin ointment, one 
drachm (4.) to the ounce (32.), deeply and thoroughly passed into 
the meatus on a camel's-hair brush. French authors generally 
recommend small tampons smeared with an ointment and left in the 
canal. Burnett employs two drachms (8.) of the oil of tar to one 
ounce (32.) of alcohol. Great benefit is derived from pencilling the 
indolent surfaces with solutions of the silver nitrate. The intractable 
forms almost invariably affect adults, and in them there is usually a 
history of improvement under treatment, then, in men, exposure, 
as, for example, to the wind, or, in women, excessive dancing, etc., 
and subsequent aggravation. 

Eczema of the Lids. [E. Palpebrarum.] 

Here the free edge of the lid, or the skin over the orbital margin 
of the tarsal cartilage, may be chiefly affected ; and either, both in 
children and adults. When the free edge of the lid is involved, 
there is a species of sycosis non-parasitica present, the hair- follicles 
becoming inflamed and furnishing a purulent discharge which may 
agglutinate the lids. The latter are thickened and swollen, become 
the seat of a moderate itching, are picked rather than scratched, and 



300 DISEASES OF THE SKIN. 

exhibit minute crusts between, or glued to, the hairs. The disorder 
is often accompanied by a seborrhoea of the Meibomian follicles, and 
is described by oculists under the designation of "blepharitis" and 
"tinea tarsi." Inasmuch as the facial expression is quite charac- 
teristic when the lids are thus involved, the patients exhibiting this 
form of eczema are usually set down as "scrofulous," though it 
occurs in mauy individuals with no other sign of struma, and eczema 
surely is not such a sign. 

Fissures occasionally form at the commissure of the lids. The 
disorder may complicate eczema of the other parts of the face. In 
the erythematous eczema faciei of adults, there is usually swelling 1 
with puffiness, especially of the lower lid. The conjunctiva may, or 
may not, be implicated. A chronic granular condition of the lids is 
not noted as frequently as might be suggested by a priori reasoning. 

The edges of the lid should be carefully cleansed with a weak 
alkaliue solution and soft camel's-hair brush whenever the lid itself 
is involved, then as carefully dried and auointed with cold cream. 
In acute cases the closed lids may be frequently bathed with warm 
alkaline solutions; and strips of soft lint, soaked in the same material, 
or a very dilute glycerine or carbolic acid solution, may be laid over 
the closed lids for as long periods during the day as they are com- 
fortably tolerated. In chronic cases the red oxide of mercury oint- 
ment, one grain to ten (0.06G-0.66) to the ounce (32.), has always 
been held in high esteem. Oculists, in the treatment of this affec- 
tion, are fond of using an ointment of the yellow sulphuret of 
mercury. In place of these, the unguentum hydrargyri nitratis, 
one part to six of cold cream, may be applied. Epilation of the eye- 
lashes may rarely be necessary. Pencillings with solutions of the 
nitrate of silver in various strengths are also useful in chronic cases, 
but these must be carefully confined to the lids, and not suffered to 
come into contact with the conjunctiva. Excessive use of the eyes 
must be prohibited. 

In the diagnosis, care must be taken to exclude syphilis, lupus, 
and pediculi. The author has seen but one instance of piedra of the 
eye-lashes. Instead of the ordinary nits of the lash, there were in 
this case jet-black, small pin- head sized masses of ivory-like hard- 
ness attached to the hairs. 

Eczema of the Beard. [E. Barbae.] 

Eczema may involve the region of the beard only, or may spread 
to such parts from those in the vicinage, or may, finally, extend from 
the beard to other parts of the face. The first is common, and fur- 
nishes, perhaps, the best type of the disease; the second is also 
common, but usually subordinate in importance to other trouble of 
the facial region. The last is decidedly the rarest. It is indeed a 
matter of surprise that an eczema should, as it often does, endure for 
years, limited exclusively to the region of the beard and never for 
once transgress these limits. 



LOCAL VARIETIES OF ECZEMA. 301 

This fact furnishes a convincing argument in favor of the local 
origin and of the frequency of local sources of aggravation of eczema. 
Rarely will one see a picture more suggestive to the uneducated eye 
of " scrofula " or " humors of the blood " than the face of a middle- 
aged man, with long-standing eczema of the entire region covered by 
the beard. The hairs are thinned, and fail to hide completely the 
reddened surface beneath, covered here and there with pustules or 
floors of broken pustules, dried inflammatory products, yellowish and 
greenish scales and crusts. Beneath the crust the surface is smooth, 
not lumpy, as in parasitic sycosis. The hair-follicles are not solely 
involved, as in the non-parasitic form of sycosis, but evidently they 
and also the integument between them. In recent eczema the hairs 
are not loosened in their follicles, but in chronic cases such loosening 
does unquestionably occur, and there is a true defluvium capillitii. 
The disorder is evidently one primarily involving the skin of the 
region of the beard, and secondarily the hairs, extending smoothly 
over that surface, as smoothly as an eczema on the cheek of a woman. 
There is commonly a certain degree of symmetry, to the extent at 
least of involving the beard in different degrees on both cheeks at 
once, or the chin on both sides; often the symmetry is perfect. This 
is rare in the parasitic affection of the same part. 

The disease is accompanied by itching, rarely as severe as upon the 
smooth parts of the face, is particularly obstinate, and extremely dis- 
figuring. When extending into the region of the beard from other 
parts, it is usually associated with eczema of the ears. When limited 
to the region of the moustache, it may be connected with an eczema 
of the nares and a chronic nasal catarrh. 

The explanation of the obstinacy of eczema of the region of the 
beard is to be found in the hairs which cover it. Whether the latter 
be long or short, feeble or strong, each during the twenty-four hours 
acts to a certain extent as a lever in motion upon the portion of the 
integument in which it is implanted. In conditions of health, the 
skin tolerates well this motion ; in disease it becomes a positive source 
of trouble. Multiply by thousands the impression produced upon 
the healthy skin when a single hair or group of hairs is moved by a 
strong current of air, by the fingers, by a brush, or by any other 
externally operating cause, and some idea may be had of the extent 
to which this force may become effective. But the best evidence of 
the fact is to be found in the results which follow the removal of the 
beard. Clipping short the hairs of the face will not answer, though 
generally preferred by the patient as exposing to a less degree the 
unsightly surface beneath. Nothing short of shaving, and continual 
shaving every second day, will effect the desired result in chronic 
cases. As soon as the disease is reduced practically to an eczema of 
the non-hairy parts, it improves, in proportion to its distance from 
the mucous outlets of the body. When limited to the bearded cheeks, 
the most obstinate cases may be in the course of a single month 
robbed of one-half of their unsightliness. It may be needful to 
employ the usual methods — oil, hot water, and soap — to remove the 



302 DISEASES OF THE SKIN. 

crusts before the first shaving, and any imprisoned pus should be 
evacuated. The patient should he encouraged by reminding him 
that usually it is but the first step which costs; each succeeding re- 
moval of the beard is accomplished with greater comfort to himself 
physically and mentally. After each shaving, the skin should be 
bathed in water as hot as tolerable, and, if at night, a lotion may be 
used, or an ointment, or the latter after the former. The salves most 
useful for this purpose are sulphur, one drachm to the ounce (4. to 32.); 
the diachylon ointment with salicylic acid, five to ten grains to the 
ounce (0.33-0.66 to 32.), and the zinc ointment. Best of all, however, 
is the dusting powder; and, as soon as practicable, the patient should 
limit himself to this application. The shaving should be continued 
for months after the disease is at an end. It is indeed surprising to 
note in such cases how quickly the "scrofulous" look disappears, and 
the evidences of a " humor of the blood" are no longer evident in 
the face. The longer the limitation of the disease to the region of 
the beard, the more brilliant, as a rule, is the result. It is not often 
necessary to resort to the tarry applications in this form of the affec- 
tion. When complicated by eczema of the post- or infra-auricular 
region, stalactite-shaped crusts depending from the infiltrated lobule 
in consequence of the unintermittent drip of serum from above, eczema 
of the region of the adjacent whisker is less readily managed. 

Flat epitheliomata of the bearded cheek are not to be confounded 
with eczema barbae. The points of difference have been previously 
noted. It should be remembered also that the age of the patient, the 
career of the disease, the possible eversion of the neighboring lid, or 
agglutination of the adjacent lobe of the ear, distinctly high eleva- 
tion, or ulceration of tissue, absence of itching, and distinct localiza- 
tion of the disease are all characteristic of this form of carcinoma. 

Eczema of the Genital Organs. [E. Genitalium.] 

Here the disease is remarkable for the severity of the subjective 
sensations it occasions ; for its tendency to persistence, recrudescence, 
and nocturnal exacerbation, and for the liability to the production of 
the sexual orgasm by the act of scratching. In men the surface 
most often involved is the anterior, posterior, or lateral faces of the 
scrotum where they meet the thigh, though the surface of the penis, 
as also that of the pubes and perineum, may be involved. In 
women, the labia majora, more rarely the labia minora and vestibule 
of the vagina are affected, with occasional extension of the disease to 
the same contiguous parts as in men. 

Eczema thus located is, as a French writer has well said, "a dry 
disease in a moist locality." Vesicular and pustular forms are much 
rarer than the erythematous, the papular, the papulo-squamous, and 
the erythemato-squamous. In women, the moister forms are more 
frequent, doubtless because of the wider mucous outlet, and the more 
extensive mucous tract in the vicinage. The labia are then heightened 
in color, oedematous, agglutinated by crusts, and often torn viciously 



LOCAL VAEIETIES OF ECZEMA. 303 

by the finger-nails. Blood-crusted excoriations are seen in most 
severe cases. An eczema intertrigo at the labio-femoral angle is 
common. Over the whole may be poured the secretions from uterus 
or vagina, normal or pathologically altered. The disease is, however, 
sufficiently common after the menopause, when there is physiological 
atrophy of the uterus. 

The typical disease in men is recognized in the thickened, 
reddened, perhaps slightly scaling integument of the scrotum, which 
may also be fissured, excoriated by the nails, or covered by blood- 
crusts. Torn papules, often closely packed together, may be seen 
with a peculiarly lurid, even purplish hue. In exaggerated cases the 
infiltration is so great as to deform the parts, increasing the thickness 
of the scrotal integument to many times its normal dimensions, pro- 
ducing thus an elephantiasic appearance. In eczema of the penis the 
prominent symptoms are also oedema, itching, and redness, with slight 
scaliness. 

In both sexes, as before stated, the attempts to relieve the 
itching are often as severe and prolonged as they are ingenious. 
Commonly no relief is obtained till a serous sweating or weeping of 
the thickened tissues is induced by the friction. Inasmuch as the 
latter is in severe cases frequently repeated, the physical dangers are 
obvious. 

Apart from this, however, the disorder has a marked tendency to 
disturb the mental tone and the general health. Shame deters many 
from seeking speedy relief, so that cases of long standing are those 
more commonly registered by the physician. Though entirely 
unconnected with venereal disease of every kind, there is, for the 
many, a special dread of an eczema of these parts, precisely because 
of its location. With sleep disturbed, the mind agitated, and the 
nervous system teased by an intolerable pruritus, one can scarcely 
wonder at the eloquence with which many patients describe their 
sufferings. It is a disease of middle life and advanced years. It is 
rare to see a well-marked, obstinate case in a child. 

The causes, exciting and aggravating, of eczema of the genital 
region are to be sought in heat, moisture, and friction. These 
primary factors are favored — first, by the effect of gravity, the organs 
in question being situated, when the body is in the erect position, at 
the inferior apex of the double cone forming the trunk, and being 
thus subject to the force of gravity ; second, by the arrangement of 
the clothing in both sexes, by which heat and friction effects are 
heightened ; third, by uncleanliness, the secretions and discharges 
from the adjacent mucous tracts being suffered to accumulate upon 
the person ; fourth, by a long list of sexual errors which operate by 
obstructing what may well be termed the sexual ebb — that is, the 
natural reflux by which each periodical physiological congestion of 
these organs is by a natural process relieved. That the skin of these 
organs participates in such periodical congestion is a fact demon- 
strable to the eye. The abundant supply of bloodvessels, lymph- 



30-1 DISEASES OF THE SKIN. 

atics, and nerves to tlie parts, furnishes all necessary elements for the 
explanation of the formidable series of symptoms often displayed in 
eczema genitalium. , 

In many eczemas of the surface, especially of the genital organ-, the 
urine will be found to contain albumen or sugar, and these conditions 
have been supposed to lie at the root of the eczema. One author has 
even prescribed a diet for the eczematous patient with saccharine 
urine The explanation of the phenomenon is, however, sufficiently 
simple. It is the eczema which causes the elimination of the sugar 
or albumen, and not the reverse. Sugar and albumen are known to 
be producible in urine by external irritants, and, among the latter, 
by cutaneous diseases. Merely varnishing a portion of the skin has 
been followed by these effects. If patients with saccharine urine and 
severe genital eczema can be kept in bed, in the recumbent position, 
for a few days, while any soothing application productive of comfort 
is continuously applied to the tender and excoriated surface, the 
sugar will often rapidly disappear from the fluid excreted from the 
kidneys. These renal symptoms are in part reflex, resulting from 
the extraordinary irritation of the nerves distributed to the involved 
surfaces. 

The so-called diabetidcs genitaks of French authors may include 
some genital eczemas occurring in diabetic patients. But it is certain 
that many cases of very extensive and severe eczemas of the genital 
region in both sexes occur in patients in wdiom the most careful and 
repeated examination of the urine fails to reveal traces of sugar. 
The practitioner is urged never to omit such examination in his 
treatment of a typical case. 

The treatment is to be conducted on the general principles hereto- 
fore enuuciated. Sponging of the genital region with alkaline water 
as hot as can be well tolerated, followed by the blander oils and 
ointments at night, and the use of anti-pruritic dusting powders in 
the daytime, must not be omitted. In eczema of the scrotum, the 
suspender lined with lint which is wet with a lotion, smeared with 
an ointment, or thoroughly covered with a powder, can be usually 
employed to good advantage. The habit of scratching must be 
broken up at all hazards. In chronic cases, the treatment by soft 
soap and diachylon ointment will be found useful. Caustics, solu- 
tions of the mercuric bichloride and other mercurials, carbolic acid, 
and especially the tarry compounds, are often necessary. 

Finny, of Dublin, uses the following formulae, which are useful in 
allaying the irritation : 

R. Liniment, calcis f<§iv; 128 



Liniment, calcis 


f£iv 


Belladonn. extr. 


gr. xij 


Zinci oxid. 


oij 


Glycerini 


f3ij 


Aq. calcis 


f3iv 



128 M. 

Lotion to be applied at night after bathing the parts in hot 
water." 



LOCAL VARIETIES OF ECZEMA. 305 



. Lin. calcis. 


fgiv; 


128 


Acid, hydrocyanic, (dil.) 


m ; 


4 


Liq. plumbi subacetat. 


fsij ; 


8 


Glycerin. 


m ; 


8 


Aq. ros. ad. 


f^vnj ; 


256 



M. 

Sig. " Cream, for application on strips of old linen. 

Exceedingly obstinate eczema of the pubic region is benefited by 
shaving and subsequent appropriate treatment. When complicated 
by intertrigo, the latter condition requires special relief by the inter- 
position of soft lint spread with an ointment. 

The diagnosis is between ringworm of the genitals, acne, pruritus, 
pediculosis, the venereal disorders, aud herpes progenitalis. The 
first named may occur alone, or induce, or be grafted upon the eczema. 
It will be recognized by the discovery of the trichophyton, and is 
clinically distinguished by the crescentic edge of the spreading patch, 
with its convex border looking away from the genital centre. The 
"follicular vulvitis" of gynecoolgical authors is a genital acne, and 
manifestly limited to the glands and peri-glandular tissues. The 
same is true of bromine and iodine acne, which may be developed in 
the same situation in both sexes. Genital pruritus may beget an 
eczema by scratching, but is accompauied by no proper skin lesion. 
The pubic louse is visible to the eye, as are also its reddish excreta 
and nits. The ulcers and sclerosis of the chancroid and primary 
syphilis are not accompanied by pruritus, and though occasionally 
multiple, never exhibit diffuse patches of disease. The syphilo- 
dermata are recognizable by their characteristic features, and by the 
history of an infectious disease. In herpes progenitalis there are pre- 
cedent burning, smarting, or neuralgic sensations, the occurrence of 
vesicles or groups of vesicles (lesions rare in eczema of the genitals), 
and frequent limitation of the disorder to the mucous surfaces or the 
rnu co-cutaneous lip by which such surfaces are bounded. In eczema 
such boundaries are usually respected, and the disease is much more 
strictly cutaneous. 

Eczema of the Anus and Anal Region [E. Ani] 

in its etiology and characteristics is closely allied to the same disease 
in the genital region. The presence of ascarides and haemorrhoids 
occasionally induces or aggravates the disorder ; though this is rarer 
than is commonly supposed, since multitudes of men and women who 
suffer from piles never complain of eczema. The eczema may occur 
in erythematous, squamous, or papular form, in the order named ; 
thus exhibiting here, as in the genitals, " a dry disease in a moist 
locality." 

The redness, infiltration, and itching, may be limited to the verge 
of the anus, radiate from the latter in stellate lines, creep upward 
between the nates in the cleft, sweep forward over the perineum to 
the genital region, or extend laterally with intermediate intertrigo 
over the inner face of each thigh. Rarely the buttocks are covered 
with the same lesions. 

20 



30*3 DISEASES OF THE SKIN. 

The disease is common in infancy, where want of care in the 
removal of the napkin is a fertile source of mischief; and also in 
middle life and advanced years, when it becomes particularly intract- 
able. The itching is intense in the latter class, with frequent noc- 
turnal exacerbation. Unfortunately the scratching is often reflex, 
and practised during the unconsciousness of sleep, from which the 
patient is often roused by his or her manipulations. Pollutions fully 
recognized, or occurring during profound sleep, or, more usually, 
in states of semi-consciousness, complicate certain cases; defecation 
becomes painful. The harassed nervous system of the sufferer is 
often in a deplorably wretched condition. In cases of long standing 
the usual congested, thickened, infiltrated, aud almost elephantiasic 
appearance is presented, with exaggeration of the natural furrows 
and occasional fissures. The part may simulate in aspect the formid- 
able conditions discovered in passive pederasty. Excoriations are 
common around the anal verge. 

The diagnosis is that of eczema of the genital regiou. 

In the treatment of these cases the use of very hot water by 
sponging, and the subsequent application of ointments, has yielded 
the best results. In the case of infants the dusting powders and 
blander ointments are alone to be employed ; in adults, especially in 
chronic cases, the tarry applications are especially valuable. Here 
the tincture of tar may be freely painted over the surface, or one of 
the tarry ointments, such as the Wilkinson salve, of sufficient firm- 
ness to retain its form as an unguent when subjected to the heat of 
the part. Caustics are useful when there are fissures. Corrosive 
sublimate, one-half to one-quarter of a grain (0.033-0.016) to four 
ounces (128.) of the milk of almonds; Squire's glycerole of the 
plumbic subacetate, half a drachm (2.) in two ounces (64.) of glycerine 
and water, or, as a substitute for the latter, the soft soap and dia- 
chylon plaster, are here of special service. Van Harlingen recom- 
mends almond oil containing twenty per cent, of carbolic acid. 
When defecation is painful the stools should be semi-liquid in order 
to insure non-aggravation of the local disorder ; not, it need scarcely 
be remarked, with a view to eliminating any materies morbi by purga- 
tion. Small tampons of cotton may be smeared with an emollient 
ointment, and gently inserted for a short distance within the anus. 
Kaposi recommends butter of cocoa suppositories, containing zinc 
oxide with belladonna or opium. When complicated by true fissure 
of the anus the sphincter ani must be stretched, divided, or dilated 
with medicated bougies. 

Besnier recommends the use of a clyster after each bowel movement, 
the fluid being retained for but a short time. At night, a cataplasm 
is applied. The parts are frequently washed with tepid water, and 
the anal tampons are smeared with cocaine. During the day, the 
oxide of zinc salve, thirty grains (2.-32.) to the ounce of vaseline, 
is applied, and the parts are also thoroughly sprinkled with equal 
parts of the zinc oxide and subnitrate of bismuth in fine powder. 
Vau Harlingeu suggests after the use of the hot bath, with the 



LOCAL VARIETIES OF ECZEMA. 307 

addition of starch and glycerine, an ointment composed of one part 
of cod-liver oil to two parts of suet. Veiel prefers the cautious use 
of chrysarobin to tar, employing the latter either in the form of 
spirits or as a tar diachylon, one part to twenty, gradually increased 
in strength. Carbolic acid and glycerine, a few drachms of each to 
the pint of elder-flower water or almond emulsion, are specially indi- 
cated in fleshy women when the disorder, as is often the case, is com- 
plicated with intertrigo. 

Eczema of the Nipple and Breast of Women [E. Mammae] 

is common in nursing women from either the irritation produced by 
the mouth of the infant, or, more commonly, in consequence of a 
galactorrhoea. Eczema intertrigo is common below and between the 
breasts. The eczema here is vesicular, erythematous, or squamous 
in form, with fissures of the apex, side, or base of the nipple. The 
serous ooze from the infiltrated areas dries as usual into light-colored 
crusts. There are the characteristic burning and itching. The 
disease may occur on one or both breasts, and, especially with a 
galactorrhoea in summer, may spread extensively, covering both 
breasts, the surface of the belly, and the intermammary region. The 
circumscribed forms occur also in pregnant or unmarried women, and 
are to be distinguished from scabies, which in women is apt to occur 
upon the breast. 

u Paget' s Disease of the Nipple," or "malignant papillary derma- 
titis," the so-called eczema of the nipple and cancer of the breast, is 
designated by Thin 1 as a destructive or malignant papillary der- 
matitis. The mammary tumors here formed are found to originate 
in the epithelial lining of the lactiferous ducts, the elements of which 
undergo, at an early period of the disease, a cancerous transforma- 
tion. Clinically, there is usually observed in such cases a sunken 
nipple, its site occupied by a bright red or livid infiltrated patch of 
distinct outline, differing thus from the irregular definition of the 
contour of the eczematous area. In all cases of subcutaneous tumor 
or coincident axillary adenopathy, the physician should be especially 
careful in the matter of prognosis. 

The treatment is in general that described above. In severe cases 
with galactorrhoea, nothing short of weaning the child and a cessa- 
tion of all demands upon the breast will insure relief. Every effort 
should be made in milder cases to avoid this dernier ressort. At 
first, scrupulous care; pencillings of fissures with a crayon of silver 
nitrate or the tincture of myrrh; gentle anointings with emollient 
zinc, thymol, or carbolic acid ointments, which should be carefully 
washed off before the child is put to the breast; and, finally, dusting 
powders, with soft lint retained between and beneath the breasts, are 
measures to be tried. Later, the sublimate solutions, diachylon oint- 
ment or naphthol, two per cent, in alcohol, may be employed. Veiel 

1 London Lancet, Amer. ed., p. 533, June, 1881. 



308 DISEASES OF THE SKIN. 

recommends the application to all fissured nipples of Lister's borax 
salve : 



R. Acid, boracic. subtil, pulv. I -_- 
Cerse alb. j ° 

Paraffin. ) -- _. 

01. amygdal. j 



ME. 



Fournier recommends a breast-plate of caoutchouc. When limited 
to the nipple and areola in nursing women, the glass aud rubber 
apparatus sold in the shops may be tried in the hope of saving the 
nipple from the mouth contacts in nursing. Sometimes they answer 
admirably; often they fail utterly. 

Paget's disease of the nipple should be treated as a carcinoma, and 
may eventually require removal of the breast. 

Eczema of the Umbilicus. [E. Umbilici.] 

This local variety of the disease is briefly described in the chapter 
devoted to seborrhea. In most cases it is either induced or aggra- 
vated by a local seborrhcea fluida, which gives origin to the peculiarly 
nauseating odor characterizing the disease. Generally a reddish and 
infiltrated, more or less annular patch surrounds the umbilical 
depression, which may be filled with crusts. Syphilodermata, pedi- 
culosis, and scabies in womeu are to be carefully excluded in -the 
diagnosis. The liquor sodre chlorinatse, carbolic acid solutions, and, 
in chronic cases, iodized phenol will be required in its management. 
Care should be taken that the dressing of the navel in the newly 
born infant, the improperly adjusted apparatus for retention of an 
umbilical hernia, and the corsets or "uterine supporters" of women, 
do not occasion or aggravate the disease. 

Anderson reports that in typical cases, especially of those affected 
with scabies, the navel is swollen and projects in the form of a small 
tumor. 

Eczema of the Superior and Inferior Extremities. 
[E. Membrorum. E. Crurale.] 

The flexor surfaces of the extremities, especially in the vicinity of 
the joints, are particularly prone to exhibit symptoms of the disease. 
With these should be properly included the axillary and inguinal 
spaces. In all such localities the alternate tension and relaxation of 
the integument serve when the limbs are in motion, to increase the 
pruritus, aud, correspondingly, to aggravate the disease. Often a 
certain degree of symmetry can be perceived, the two popliteal spaces, 
for example, being simultaneously affected, though each to a different 
degree. The parts most favorable for the complications of intertrigo 
are those nearer the trunk where the moisture and heat are greater, 
as the groins and axilla?, while the elbow and popliteal spaces are 
more frequently dry, exhibiting papulo-squamous ridges in lines at 



LOCAL VARIETIES OP ECZEMA. 309 

right angles to the axes of the limbs, with hypersemic patches on 
either side. 

Upon the legs, where the force of gravity is more potent than in 
other parts of the body, exaggerated forms of eczema are found 
complicated with varicose veins and oedema, with dense infiltrations 
and indurations. In ancient cases the frequent elephantiasic aspect 
is significant, one limb being by several inches larger in circumfer- 
ence than its fellow, covered from knee to ankle with enormous 
patches of eczema rubra m of an intensely angry appearance, moist 
and crust covered ; or dry, glazed, and of a lurid reddish hue ; or 
dry, horny, and ridged with irregular projections surmounted by 
scales resembling the rough bark of a tree ; or, again, with or without 
oedema, tense, inelastic, seamed with scars of old varicose ulcers, and 
deeply and irregularly pigmented, a condition with great difficulty 
distinguished from syphilitic ulceration of the same region. At its 
onset, eczema of these parts may assume any one of its known forms. 
In infants with long clothing, where the lower extremities are sub- 
jected to a higher temperature than in adults, the vesicular and 
pustular forms are common. The exceedingly obstinate forms of 
eczema of the legs, especially those complicated with varicose veins, 
are, of course, those encountered in middle life and advanced years. 

The diagnosis is, in general, to be established by considering the 
points heretofore discussed. The chief difficulty lies in distinguish- 
ing the eczema associated with ancient varicose cicatrices of the leg, 
from syphilitic scars of the same locality which have resulted from 
degenerating tubercular syphilodermata or gumtnata. In some cases 
when no distinct history can be obtained, there will be a necessary 
doubt, as the force of gravity upon the vessels, even without vari- 
cosities, produces certain common features notably deep pigmenta- 
tion in both classes of cases. In women, the sexual history is all- 
important, including the order of abortions, miscarriages, and viable 
infants. In both sexes, the discovery of other lesions, and especially 
of characteristic cicatrices elsewhere, must be attempted. It will be 
remembered that the syphilitic ulcer tends to the shape of a circle 
or segment of a circle, and though occasionally existing as the sole 
lesion upon one leg, it is frequently multiple, or may involve both 
extremities, the pigmentation in old cases occurring chiefly at the 
periphery of the scar. Very extensive pigmentation about ancient 
cicatrices, especially disposed between irregularly defined scars, is 
truer of eczematous forms, as the pigmentation due to syphilis, though 
long-lived, is yet the more ephemeral. With periosteal nodes the 
diagnosis is clearer. 

The treatment of eczema of the extremities does not differ from 
that described above, except as regards the indications to be met 
relative to support of the parts, thus counteracting the effect of gravity. 
Excellent results are here obtained by the use of the pure rubber 
bandage, applied immediately next the skin, especially in cases com- 
plicated by oedema, ulceration, and venous varicosity. The method 
of applying the well-known Martin bandage has been made generally 



810 DISEASES OF THE SKIN. 

familiar to the profession ; and for details respecting its availability 
in eczema of the leg, the reader is referred to the essay on Eczema 
and its Management, by Dr. Bulkier, of New York, 1 who is enthusi- 
astic in its praises. 

Such treatment, however, deserves only subordinate rank in com- 
parison with the essential rest of the affected limb in the horizontal 
position. With a grave eczema of the lower extremity, such rest 
should be enforced ; and patients whose limbs have proved rebellious 
under the rubber (for such there are) may thus be relieved. The 
local applications to be made meanwhile are those adapted to the 
particular features in each case present. 

To a less degree, the same may be said of the arms. In these 
localities, it is rarely necessary to resort to elastic pressure. In all 
cases, however, a neatly applied bandage over the dressings will add 
the effect of pressure and support, and generally contribute to the 
comfort of the patient. A favorite dressing, in dry, papular, erythem- 
atous, and squamous patches of the disease, is applied as follows : 
The parts are first bathed with hot alkaline water for several minutes 
till the itching is relieved, and then carefully and thoroughly dried. 
The patch is then completely covered with a dusting powder, which, 
according to the indications of the case, is either emollient, astringent, 
or stimulating. Finely powdered tannin with French chalk ; or even 
pure calomel ; or bismuth, zinc, and starch, may be thus used. Over 
the whole, strips of Maw's surgical plaster are alternately and neatly 
superimposed in the manner some years ago recommended by Baynton. 
A snugly fitting rubber bandage encompasses the whole. The dress- 
ing is left in situ as long as it is comfortable, often for two or three 
days, when it can be removed. In properly selected cases, the itching 
is relieved, the infiltration reduced, and the patch soon loses its 
hyperaemic aspect. Occasionally no other treatment will be required. 

Nor should it be forgotten that with care and patience, the starch 
bandage of the leg, the plaster-of- Paris dressing over folds of Canton 
flannel arranged so that it may be removed at pleasure in the manner 
in which it is used by some surgeons in the treatment of diseases of 
the joints, these and other immovable dressings may accomplish even 
more in obstinate cases than elastic apparatus. 

For the exudative phases of eczema of the leg, the forms so often 
seen here of eczema rubrum, the gelatine medicated plaster meets the 
indications well. Morrow makes this by adding two hundred and 
fifty parts of glycerine to one thousand of gelatine, and two thousand 
of water medicated with ten per cent, of the oxide of zinc and one 
per cent, of carbolic acid. It may be left in situ several days and 
furnishes a smooth, elastic, and uniform coating. 

Eczema of the Hands and Feet. [E. Manuum. E. Pedum.] 

No more striking illustration of the significance of the etiology of 
eczema can be adduced than that to be discovered in the hands. By 

i G. P. Putnam's Sons, N. Y., 1881. 



LOCAL VARIETIES OF ECZEMA. 311 

these organs man toils to earn his bread, and the eczema they display- 
is their protest against the rude contacts which are thus necessitated. 
Unfortunately, in too many of such patients the imperative necessity 
of bread-winning forbids consent to the best method of relief, viz., 
temporary disuse of these organs. The feet may or may not be 
similarly attacked, and for similar reasons. All forms of eczema are 
here seen, erythematous, vesicular, papular, pustular, and squamous, 
involving the entire surface, or limited to the wrists, ankles, inter- 
digital spaces, palmar or plantar surfaces, or one or more digits on 
either face. The motions of the part are so free, that fissures are 
-common and often exceedingly painful. The itching may be severe, 
and the parts of one hand or foot extensively rubbed, torn, or abraded 
by the other. Vesicles are more frequently encountered upon the 
more delicate portions of the skin, as over the dorsum and interdigital 
spaces, while in the denser palm and sole they are represented by 
sub-epidermic points from which by puncture a clear serous or cloudy 
fluid may be evacuated. Usually, however, in the regions last 
named, there is a dry, dead-whitish or hypersemic, uniformly indu- 
rated and thickened integument, which may be fissured or produce 
such a tense inelasticity of the surface that the fingers are semi-flexed 
into the palm, or, much more rarely, the toes rendered considerably 
less extensible. 

Circumscribed patches of eczema, with fairly defined outline, red- 
dish in color beneath crust or scale, subacute in course, and accom- 
panied by paroxysmal itching, are of common occurrence on the 
dorsum, and also in the palm or sole. In the latter situation, they 
may be traversed by one or more painful fissures, the same being 
true of the dorsum of the fingers and toes. Upon the back of the 
hand, these circumscribed patches are apt to assume an indolent course, 
improving temporarily under appropriate treatment, and becoming 
aggravated by every exposure to the causes by which they were first 
induced. 

The long list of etiological factors which may here be efficient can 
scarcely be enumerated. Several have already been considered in 
discussing the causes of eczema in general. The influence of all 
articles handled in the trades, occupations, and professions of life, as 
well as of the action of toxicants and dyes, must be remembered. 
Thus printers, bakers, aud masons suffer in the hands ; and the 
wearer of dyed stockings, and coarse, ill-fitting shoes and boots in the 
feet. Because needle-women are often overworked, nervous, pale, 
and thin, their digital eczema, really due to the implements and stuifs 
they handle, has been erroneously attributed to their general condi- 
tion. The poor seamstress starving for sunlight, nutritious food, and 
open air exercise, may return to her weary routine with her eczema 
quite relieved. 

In the matter of diagnosis, it should be remembered that an eczema 
of the hands may be induced by the Rhus toxicodendron, the disease 
being then liable to a transfer by contact from the hands to the face 
and genital or mammary region. Scabies of the same region is in 



312 DISEASES OF THE SKIN. 

this country much rarer than eczema manuum. In scabies the vesi- 
cles are firmer, more often unruptured, fewer, more isolated, more 
intermingled with crusts, pustules, and even bullae, which latter are 
rare in eczema. The discovery of the parasite and a history of con- 
tagion will aid in removing doubt. Abundance of pustular lesions 
in young subjects is, however, according to Hebra, most commonly 
produced by the acarus. 

The characteristic burrow made by the parasite, an irregularly 
curved, thread-like, beaded, or dotted line, about one-quarter of an 
inch in length, either running at a tangent from the unruptured vesicle 
or across its summit, is proof of scabies only second in value to the 
discovery of the parasites themselves. The occurrence of the erup- 
tion elsewhere on the body is also to be expected in the last named, 
disease, with respect to which it should be remembered that the 
burrow may not be visible, and may be wanting when the parasites 
are present. Psoriasis of the palms and soles is always accom- 
panied by the presence of patches in other parts of the body, whose 
typical characters should throw light on the local disorder. They 
are dry, non-discharging lesions, very rarely fissured as is the eczema 
of the hands, have a distinct contour, and are covered with more 
abundant and more lustrous scales. The scaling syphilodermata of 
the palms and soles occur early and late in the disease, and usually 
after a distinct history of infection. The lesions in syphilis are 
usually isolated, firm, deep infiltrations, circular in outline, with" 
very sharp definition, and may be covered by dry, adherent, dirty- 
white scales, beneath which the brown and red hue of the persistent 
lesion can be discovered. Superficial or deep circular excavations of 
tissue are visible, single or multiple, with punched or ragged edges. 
The eruption is rarely, like eczema, accompanied by itching or dis- 
charge, but painful fissures may form. It occasionally affects the 
dorsum of the hand or foot, favorite sites of eczema manuum, but 
almost invariably has in such cases swept thither from the palm or 
from the sole. 

In both syphilis and eczema of the hand, the right organ in right- 
handed laborers is invariably most involved, even when there is 
apparent symmetry of distribution of lesions. 

The treatment demands, first, rest for the organs, and a simulta- 
neous discontinuance of the exciting cause. In the trades, the result of 
the latter can be usually demonstrated by the patient, who notices the 
difference between the condition of the skin on Monday morning after 
a Sunday's rest, and that which was distressing on the precediug 
Saturday night. When practicable, protection during labor must be 
secured by the use of gloves, finger-cots, rubber-stalls, or bandages, 
neatly applied and retaining dressings to the part of the hand or foot 
which is the seat of the disease. For circumscribed, non-discharging 
patches on the dorsum of the hand or foot, the dressing described in 
connection with eczema of the extremities may be applied. When the 
nature of the labor performed is such as to render it impossible to 
secure protection of the hands or fingers in this way, something may be 



LOCAL VARIETIES OF ECZEMA. 318 

accomplished in a few cases by directing that the hand be frequently 
dipped into a protective solution, or powdered during the hours of 
labor. Thus printers may dust their fingers with lycopodium, and 
those compelled to retain their hands in irritating solutions, can 
anoint these organs occasionally with an oily or fatty substance. 
Generally it may be said that an eczema of the hands is too fre- 
quently washed, and the ill effects of such practice are made evident 
not only in laundresses, but in mothers who personally attend to the 
dressing of young infants. The local applications made to each case 
may be those described above as suitable to each stage of the disease. 
When extensively involved, the hand should be carefully dressed, 
each finger being separately wrapped in soft linen rags smeared with 
camphorated or carbolized, pure or diluted, linimentum calcis in 
acute cases ; or, later, with a bismuth, zinc, or mercurial ointment. 
The tarry compounds are here very useful ; and the caustics more 
than ever needful when there are fissures. Protective flexile collo- 
dion plays an admirable part about the nails where irritable seams- 
and fissures form with overhanging fringes of a torn and ragged 
epidermis, bordered with red. In all painful eczemas of this region 
the immersion, particularly at night, of the entire hand or foot in 
hot water should be practised, followed by careful drying and 
anointing with a salve or an oleaginous semi-liquid. This should 
be spread thickly upon pieces of muslin, wrapped neatly about each 
finger separately, and other affected parts, and the whole covered 
with waxed paper. The Lister protective gauze, or a pair of rather 
large undyed gloves which can be readily drawn over the whole, may 
be substituted for the former. 

When the epidermis of the palm is greatly thickened, it should be 
shampooed at night with green soap, pure or in spirit, by the aid of 
hot water, followed by a salve containing either the white precipitate,. 
ten to twenty grains to the ounce (0.66-1.33 to 32.), or the Wilkinson 
tar salve. For intractable cases, caustic potash, in the strength of 
twenty to thirty per cent, solutions, can be mopped well into the 
thickened palm, and followed by a salve-application. Van Harlingen 
suggests : 



R . Hydrarg. ammoniat. J}j ; 1 

2 
10 

24 



Hydrarg. ammoniat. 


9j; 


Adipis 


3ss; 


Sevi benzoinat. 


9vij ; 


01. amygd. dulc. 


ttlx; 


Vaselin. 


ad 5vi ; 



M. 



For the fingers and hands, Unna's mull plasters fill very perfectly 
every requirement. These may be cut into strips, and applied with 
neatness to every digit. The zinc oxide, tar, and ichthyol mulls are 
all available for this purpose. 

Eczema as it Affects the Nails [E. Unguium.] 

There is nothing characteristic of eczema in its effects upon the 
nails. These horny plates participate in the diseases which affect 



814 DISEASES OF THE SKIN. 

their matrices, and thus exhibit nutritional changes. There is, there- 
fore, no eczema of the nail proper, but only an eczema of the digit 
by which the nail is affected. In well-marked cases, one, several, or 
all of the nails of either hands or feet may lose their polish, or 
become rough, punctate, furrowed laterally, and clubbed, or present 
an appearance suggestive of worm-eaten surfaces. They lose their 
uniformly smooth attachment beneath, and become tilted on their 
beds, with marked friability of their tissue. In such cases, an eczem- 
atous condition of the skin at the margin may be detected, where 
the usual redness, infiltration, and scaling, with a sensation of itching, 
point to the nature of the trouble. Rarely the nails are shed. The 
most misshapen will be succeeded by smooth and natural growths of 
nail-substance, if the disease of the matrix be completely relieved. 
The treatment, therefore, is the treatment of the cutaneous disease. 
Care must be taken to exclude ringworm of the nails, which end can 
be reached by microscopically examining the scales scraped from the 
uail-surface. 

The zinc oxide and tar salves will be found most effective for the 
larger number of cases. Often the organs may be with advantage 
protected during the daytime by the combination of gelatine and 
glycerine described in the management of eczema of the extremities. 

Eczema of the Tropics (Prickly Heat). [E. Solare. Lichen 
Tropicus, etc.] 

Under these titles have been described a number of disorders, some 
of which are more closely related to the forms of sudamen described 
in connection with the functional derangements of the sweat appa- 
ratus, some of which are instances of papular eczema, associated or 
not with profuse sweating under the influence of high temperatures 
(solar heat, tropical climates, hard labor in the heated air of engine- 
rooms, etc.). The disease is aggravated by all external and iuternal 
sources of irritation, including alcoholic beverages, opiates, flannel 
garments worn next the skin, undue exertion in a heated medium, 
fatigue, and obesity. 

Etiology. — The disease is more common in those subjected to rapid 
and intense fluctuations in the temperature of the atmosphere than in 
those long accustomed to a relatively hot climate. It is thus ex- 
ceedingly common in the northern parts of our own country, where 
the absence of a regulating Gulf stream ushers the inhabitants sud- 
denly from the rigors of a severe winter to the prostrating heats of 
summer. It attacks alike individuals of both sexes and all ages, 
being often particularly severe in the obese and in infants, whose 
delicate skins, no less than their bowels, resent sudden and severe 
thermal changes. It moreover affects equally those who are vigorous 
and the debilitated. 

The disease is characterized by the occurrence of pin-point to pin- 
head sized vesicles, bright-red papules, vesico-papules, or the two as 
coincident and commingled lesions. They are exceedingly numerous, 



LOCAL VARIETIES OF ECZEMA. 315 

and may in severe cases cover almost the entire so-called non-hairy 
surface of the body, though they may be much more limited in their 
diffusion. They are usually acuminate and discrete, though often 
very thickly set together. They are rapid of occurrence, but may, 
in consequence of persistence of the cause, be slow to disappear or 
recur repeatedly. Whether vesicles be or be not present, the affected 
region is usually bathed in sweat. The eruption is accompanied by 
characteristic sensations of tingling, pricking, and burning; its 
lesions, even though generalized, may be most vivid or most dis- 
tressing about the trunk, axillae, head, neck, or extremities. It may 
last for but a few days, or be severe for a week or more. It is un- 
questionably seen in the severest grade among fleshy Europeans, or 
Americans emigrating to tropical climates who are habitually ingesting 
alcoholic beverages in excess. 

The local treatment of prickly heat is, in brief, that of the cor- 
responding stage of eczema. Unguents are generally to be avoided, 
as the skin rarely tolerates them, and the same may be said of plas- 
ters and very cold baths. Baths or lotions, tepid, warm, or moder- 
ately cool, as the feelings of the patient may decide, to be most 
grateful, medicated with alkalies, bran, gelatine, or starch, will be 
found useful. After each, the skin is to be dried, not by rubbing, 
but by gently pressing dry cloths over the surface, and is then to be 
thoroughly protected by a free use of one of the dusting powders. 
When large tracts of the skin are involved, and general baths have 
been ordered, a package of " corn-starch farina " will often be found 
sufficiently well suited for such topical employment. 

Lotions may also be employed, composed of lead, or lead and 
opium, or the black wash, or alcoholic and ethereal solutions con- 
taining camphor and glycerine in the proportions given when con- 
sidering the subject of acute eczema. Modifications of the oleated 
lime-water are serviceable in severe cases, as, for example : 

R. 



Sig, 



01. lini 


fSij; 


64 


Paraffin. } 
Sapon. Castil. j 


aa gij ; 


64 


01. bergamii 


ad Oj ;' 


q. s. 


Aq. calcis 


500 


For external use. 







M. 



This makes a demulcent creamy solution which often proves 
exceedingly grateful to the skin ; and to it may be added the zinc 
oxide or dilute hydrocyanic acid, as may be required. 

The general treatment of the patient is a matter of importance. 
The cause must be removed if possible. Withdrawal from the light, 
heat, and labor of the day ; unstimulating food and drink, unirri- 
tating apparel, and rest, are of the greatest importance. The saline 
and acidulated beverages are usually acceptable to the palate, and 
useful if not drunk too cold. The chief value of Apollinaris water, 
lemonade, Vichy, and Kissengen, lies not in their action as medica- 
ments, but as supplying the water demanded by the cutaneous loss 
through evaporation. 



316 DISEASES OF THE SKIN. 

Prognosis. — The disorder may be trivial and severe, and last but for 
a few hours, or for as many months. It is usually relieved without 
difficulty, and often by domestic measures alone. It is most annoying 
and severe when complicated by the exudative process in other parts 
of the skin than the sweat-ducts and their immediate vicinage. 

Prurigo. 

Lat. prurire, to itch. 

Prurigo is a chronic, exudative, cutaneous affection, commonly beginning in 
infancy or early childhood, and continuing through life, characterized by 
the occurrence on the extensor surfaces of the extremities and also on the 
trunk, of minute, pale or reddish, millet to hemp-seed sized papules, with 
extensive infiltration and intolerable pruritus. 

Symptoms. — In this affection, pin-head to rape-seed sized, firm, 
whitish or reddish-white papules form, chiefly and primarily upon 
the extensor faces of the extremities, but from these localities 
extending gradually over the entire surface of the body. The itching 
they occasion is of the severest type. 

The earliest symptoms are usually displayed in the latter portion 
of the first year of life, in the form of an urticarial rash, which 
persists and is finally succeeded by typical papules. The latter are 
minute, often sub-epidermic, and become rapidly covered with blood- 
stained crusts in consequence of the induced scratching. Then 
ensues a long train of symptoms, including pustulation, fissures, 
excoriations, dense infiltrations, crusts formed of exuded serum and 
dried blood, oedema, diffuse dark-brown pigmentation of the surface 
in large areas, and consequent adenopathy. Fully developed, the 
disease presents in general the same physiognomy in different patients 
of different ages. The lower extremities always exhibit the severest 
manifestations of the disease, especially the thigh and leg as distin- 
guished from the foot ; though the trunk, forehead, cheeks, neck, 
arms, and head may be also involved. The protected surfaces, as of 
the axilla? and groins, except as regards adenopathy, are free from 
the disease. The general health of the patient manifestly suffers from 
the insomnia and nervous agitation induced by the state of the 
integument. Emaciation, malnutrition, and cachexia are common 
sequela?. The mental and moral tone of the patient thus harassed 
from early childhood throughout an entire life is necessarily pro- 
foundly impaired. Insanity and suicide are reckoned among its 
remote consequences. 

Mild and severe forms of the disease are distinguished under the 
terms Prurigo Mitis and Prurigo Ferox, or Agria. Incessant 
care, judicious treatment, climatic influences, and the comforts of life 
commanded by wealth, seem to determine the difference between the 
two. 

Etiology. — The disease occurs chiefly in Austria, few cases being 
recorded elsewhere. A patient was, however, exhibited at the Inter- 
national Medical Congress in London, whom both Kaposi and H. 



PRURIGO. 317 

Hebra recognized as affected with prurigo. Wigglesworth, Camp- 
bell, and others, have reported cases in this country. It is needful 
to remember that the term prurigo is here employed to designate the 
disease recognized by some authors as the " true prurigo of Hebra." 
It should never be confounded with pruritus, which, under various 
usages, may be the title of a mere symptom of a disease. Prurigo is 
more often encountered in the male sex ; is never contagious ; and 
never induced by lice ; but, according to Hebra and Kaposi, may be 
grafted upon an hereditary predisposition. " Scrofula," tuberculosis, 
malnutrition, "misery," poverty, ansemia, and filth, are held to be 
severally favorable to its development. Unquestionably the superior 
resources of the poorest classes in America will long protect them 
from the incursion of this inveterate malady. 

While the typical prurigo ferox, as described by the Vienna school 
of authors, is of such rarity that probably less than a dozen cases 
have been observed in this country, the opinion is gaining ground 
that the same disease with milder manifestations (prurigo mitis) is 
much more common here than has at times been believed. Two 
patients with severe prurigo treated by Hebra himself, found their 
way to the author's clinic with unmistakable symptoms of improve- 
ment after a residence in this country; and almost every expert in 
America has observed cases of the milder type. 

Pathology. — Kaposi practically admits that, striking as is the 
clinical portrait of this disease, its anatomical features are indistin- 
guishable from severe forms of obstinate papular eczema. The 
microscope reveals merely an hypertrophy of the various elements of 
the epidermis and derma, deposits of pigment in the corium, thick- 
ening of the root-sheaths of the hairs, enlargement of the cutaneous 
muscular elements (erectores pilorum), and a consequent atrophy of 
the integument which has long been the seat of the disease. 

The hairs are thinner, the root-sheaths loosened, and young cells 
are collected in abundance about the follicles. Schwimmer calls atten- 
tion in this connection to the fact that many prurigo nodules are 
pierced with a hair. An spitz believes that the disease is in fact a 
sensori-motor neurosis without essential lesion. Riehl 1 regards it as 
a chronic form of urticaria. Morison 2 regards the prurigo papule as 
formed by an infiltration beginning around the upper plexus of vessels 
in the corium, which thence spreads to the papillary vessels, enlarging 
the papilla?, elevating the epidermis, which at an early stage becomes 
thickened above them. Finally the latter is penetrated, and within 
its strata a vesicle forms, containing serum, blood, and lymph-cells. 
The regions of infiltration about the hair-sheaths and sweat-ducts are 
regarded by him as secondary, and not as an essential part of the 
process. The color of the papule does not at first differ from that 
of the skin in the neighborhood, on account of the depth of the 
slight infiltration by which it is characterized, and for the same 
reason it can be distinguished by the touch before it becomes visible. 

i Archiv. f. Derm. u. Syph., 1884. 2 Amer. Joum. of the Med. Sci., 1883. 



318 DISEASES OF THE SKIN. 

Diagnosis. — Remembering the extreme rarity of prurigo in America, 
it is to be distinguished chiefly from the various forms of papular 
eczema by the location of its lesions, the course of the disease, the 
age of the patient when it is first developed, the great extent of the 
eruption, and the uniform type of its lesions. In prurigo, also, the 
fingers and toes, flexor aspects of the extremities, and face are more 
or less -pared. Under treatment eczema commonly yields at least in 
some portions of the skin while prurigo doe- not. 

From pruritus, prurigo is readily diagnosticated by its general 
physiognomy and history; its peculiar pigmentations and infiltrations; 
and by the special region chiefly affected. But, both diseases may 
complicate prurigo, especially eczema, which is then ordinarily of 
artificial origin. In pediculosis corporis, the parasites will usually 
be found upon the underclothing, while the lesions induced by the 
nails never form closely packed papules. There is something highly 
characteristic in the widely separated excoriations, puncta from 
wounds of the insects, and inflamed papules seen upon louse-bitten 
patients. 

In scabies, the characteristic burrows of the parasites will usually 
be recognized, as also vesicular and pustular lesions. Urticaria can be 
mistaken for prurigo only in the earliest stage of the last named 
disease. 

Treatment. — In Vienna, sulphur, tar, green soap, baths, and fre- 
quent anointings with oily and fatty substances have occasionally 
served to ameliorate the severe symptoms of the disease. Mercury, 
carbolic acid, boric acid, the diachylon, and zinc ointments may also 
be employed upon different portions of the skin when indicated. 

The Wilkinson salve, representing a combination of tar, sulphur, 
and green soap, has proved of special value in many cases. Vle- 
miuckx's solution (q. v.), followed by hot bathing and corrosive sub- 
limate baths one drachm (4.) to thirty gallons, has also been recom- 
mended Internally, arsenic has proved valueless, while carbolic 
acid has occasionally seemed beneficial. Cod-liver oil and the ferru- 
ginous tonics with the bitters, will naturally be indicated in many 
patients suffering from malnutrition. A generous diet and tonic 
regimen are essential to the management of most cases, the patients 
afflicted with prurigo being usually found in the most wretched 
hygienic conditions. 

Prognosis. — The disease usually persists through life. The most 
favorable conditions are those where the patient is quite young and 
surrounded by circumstances which permit of untiring provision for 
all his needs. Many authors to-day pronounce the disease entirely 
curable in the early years of life. 



ACNE. 319 

Acne. 

Gr. axpy, a point. 

Acne is an inflammatory disease of the sebaceous glands, in which appear 
usually multiple, and painful, firm, reddish, pin-head to small nut-sized 
nodules, which may result in suppuration and the formation of cicatrices. 

Symptoms. — Acne is probably the cutaneous disease of most com- 
mon occurrence, not excepting eczema. The latter affection occurs 
upon the face as often as upon other parts of the body, and is yet 
seen upon the street with far less frequency. Eczema, however, is 
more distressing in its symptoms, and for that reason physicians are 
more often consulted for its relief, the disease thus acquiring a statis- 
tical preponderance. Acne is more tolerable, and therefore more 
tolerated and less treated, especially among the poor. 

The disease is characterized in general by the occurrence of several 
and usually numerous, light red, dull crimson, or violaceous, pin- 
head to small nut-sized, circumscribed, ill-defined papules, nodules, 
tubercles, or non-projecting indurations of the skin, often commingled 
with the lesions of comedo and seborrhoea sicca. They are usually 
both slightly painful and tender, though upon this point there is a 
wide range of difference in different individuals, some patients toler- 
ating with a surprising equanimity the most extensive invasions of 
the disease. The inflammatory process, which manifestly involves 
the sebaceous glands and periglandular tissues, may result in suppura- 
tion of one or several adjacent follicles, as a consequence of which 
coalescence occurs and pea- to large nut-sized, cutaneous and subcuta- 
neous abscesses may form. In the larger number of cases, however, 
the suppuration is limited to the area of the individual nodule, every 
feature of the entire process being displayed at the same moment in 
an affected individual. Under circumstances of special aggravation, 
the disease may occur in acute forms, but it is commonly chronic; 
and such acute phases are usually accidents of the general process. 

The disease occurs chiefly upon the face, but is seen also upon the 
neck, the back and front of the chest, the genitals, and the extremities, 
the palms and soles alone excepted. It is emphatically a disease of 
the early puberal epoch in both sexes, though occasionally seen in 
middle and later life. It usually lasts, when unrelieved, for years,, 
being during this period subject to occasional exacerbations and 
remissions ; but commonly spontaneously disappears as the full 
maturity of the body is attained. In severe cases, it leaves indelible 
traces of its ravages, in the scars where suppuration has been ex- 
tensive. It occurs also in very mild and severe forms. The various 
terms used in the description of the forms of the disease refer chiefly 
to its external features. 

Acne Artificialis. 

Various substances, either applied topically to the skin or ingested,, 
are capable of producing acneifortn lesions. Among them may be- 



320 DISEASES OF THE SKIN. 

named tar, which may prove such an irritant, whether employed 
externally or internally, and, far more frequently, the salts of iodine 
and bromine after ingestion. Tar acne occurs both among workers 
in that substance, aud in those subjected to its action for the relief of 
other cutaneous disease. Pin-head to pea-sized reddish-brown papules 
then form, at the apex of which is perceptible a minute blackish 
punctum, produced by the lodgement of a minute particle of the 
medicament in the orifice of a sebaceous follicle. Pustular and fur- 
uncular lesions are, however, also produced ; and the same is true of 
bromic and iodic acne. In the latter, Adamkiewicz and others have 
demonstrated the presence of the drug in the contents of the pustular 
lesions. Chrysarobin and a number of other medicinal substances 
are capable of exerting a like effect. 

Acne Atrophica and Acne Hypertrophica 

are terms employed to designate merely the lesion-relics of the dis- 
ease. In the former, there is complete atrophy of the gland-tissue, 
indicated by a minute sunken pit in the site of the former orifice; in 
the latter there is, in consequence of the periglandular exudation, a 
thickening of the tissues about the acini, and a projection from the 
surface of persistent, pea-sized, and indurated masses. 

Acne Cachecticorum 

includes the symptoms encountered in the subjects of struma, scor- 
butus, marasmus, chloro-ansemia, and tuberculosis. The lesions 
more often develop on the trunk and extremities than over the face, 
and are papulo-pustules, pin-head to bean-sized, particularly indolent, 
and remarkable for their livid, purplish, lurid-red, or violaceous tint. 
The lesions are rarely indurated; more often they are seen as softish, 
pus- and blood-containing nodules, sluggish of career, and leaving 
minute cicatrices. Their features are due entirely to the general 
cachectic condition of the subjects in whom they occur. 

Acne Indurata. 

This is a form of the disease less frequently observed than several 
others, but one which possesses certain distinct clinical features. In- 
duration of the base of the acne papule may be noted in many cases 
of the simple form of the malady ; but in others the glands seem 
generally to be distinguished as minute, very firm nodules, with no 
tendency whatever to suppuration. The surface of the skin is often 
without marked change in color or heat, the individual lesions 
indeed exhibiting at times an unnaturally whitish aspect. They are 
felt when the finger is passed over the surface as dense, often conical 
projections, occasionally painful, and giving to the touch a sensation 
suggestive of the nutmeg-grater. Comedones may be often dis- 
tinguished intermingled with the papules. The disease, when well 
marked, is apt to be extensive, occurring with characteristic expres- 



ACNE. 321 

sion among brunette, hairy male patients well advanced to the twenty- 
fifth year. It is often generalized over the forehead, cheeks, chin, 
and the back of the neck. 

Acne Papulosa. 

Here the lesions are of a papular type, ranging in size from a 
millet-seed to a coffee-bean, whitish or reddish in color, and varying 
in the amount of firm induration at the base. They are evidently 
due to hyperplasia of the periglandular tissue, and are often com- 
mingled with pustules, papulo-pustules, and comedones. At the 
apex is often distinguished the blackish point characteristic of acne 
punctata, or a minute, greasy, yellowish-white spot, which represents 
the non-pigmented extremity of an inspissated sebaceous plug. 

Acne Punctata. 

In this variety, the acne papule is formed about a comedo. When 
examined, its apex is discovered exhibiting the characteristic blackish 
punctum of that hsion. 

Acne Pustulosa. 

This is probably the most frequently observed of all the forms of 
the disease. The lesions, as usual, are apt to be commingled with 
papules, comedones, and intermediate phases between the functional 
and exudative disorders of the glands. The pustules may be 
large or small, containing merely a droplet of pure pus, or, when a 
true furunculosis ensues, a teaspoonful or more of the same fluid 
mingled with blood and serum. This may be speedily evacuated 
artificially or accidentally, be absorbed, or remain for a long period 
of time in a species of cyst-like loculus, whence it can be finally ex- 
pressed. In aggravated cases, two or more of these pustulo-furun- 
cular depots may coalesce, forming nut-sized abscesses, or, not rarely, 
become united by fistulous tracts, through which there is free com- 
munication of the fluid contents of two or more chambers. 

Acne Varioliformis 

is the term employed, by the French especially, to designate the 
lesions elsewhere described as molluscum epitheliale, the name being 
selected in consequence of the resemblance of the latter to the um- 
bilicated pustules of variola. 

Acne Vulgaris 

is a term applied by several authors to the composite eruption 
which is common to many clinical cases. Here the various lesions 
described above are associated, usually on the face and over the 
shoulders, each in several degrees of development, often in conjunc- 
tion with the scars left by a prior eruption. 

21 



322 DISEASES OF THE SKIN. 

Etiology. — The causes of acne are in many cases exceedingly 
obscure and are probably numerous. It is common to describe the 
puberal changes in both sexes as a frequent cause of the disease, but 
one should be slow to regard a physiological crisis as a disease-factor. 
It can merely be asserted with safety that, with the growth of the 
hairs in both sexes at the period of puberty, there is an unusual 
activity of the sebum-producing function, and that this physiological 
is then the more readily perverted to a pathological activity. Need- 
less to say that tens of thousands escape acne who survive puberty. 
The disease, however, is apt to appear first at this time of life, aud, 
if not improperly treated, to disappear spontaneously when the full 
maturity of the body is attained. 

Inasmuch also as there is a close physiological connection between 
the genital function and organs, and the appendages of the skin, not 
only in man, but in the lower animals (antlers of the stag, plumage 
of birds, etc.), it seems reasonable to conclude, a priori, that the dis- 
turbances of the former may be reflected to the latter. Many facts 
support such reasoning. The effect of castration upon the male of 
many animals is displayed in the appendages of the skin. In the 
same way, perverted sexual instincts and habits, or a poorly regulated 
sexual hygiene, aud uterine disease (which is indeed often traceable 
to the causes just named) are often associated with an acne. To the 
same category belong the disturbances of the gastro-iutestinal tract, 
including constipation, dyspepsia, malnutrition from various causes, 
and the struma, tuberculosis, etc., which are responsible for acne 
cachecticorum. The medicinal agents capable of producing artificial 
acne, either by ingestion or after external application, have been 
already named. 

It should not, however, be concluded that any one of these condi- 
tions can be recognized as efficient in the majority of patients. Many 
cases of acne occur in perfectly healthy young people of both sexes. 
A careful record of cases of the disease, preserved upon blank forms 
in which is space for noting irregular performance of function in the 
other organs, will exhibit no ailment common to the larger number. 
In these, therefore, it is proper to believe that the causes of the dis- 
ease are entirely local, such as suffice merely to induce primarily 
alteration in the consistency, quantity, or chemical character of the 
sebaceous secretion, and, either as a cause or result of this, an adenitis 
or periadenitis. 

Apart from the local causes to which reference has been made, one 
should not forget that the use of cosmetics ; neglect of soap, or the 
use of the cheaper and irritating- varieties; excessive shaving on the 
part of the young man; friction from hat-bands; "frizzes," "bangs," 
and dyed veils ; too frequent fingering of the face ( Wigglesworth) ; 
improper compression of the neck by tight collars ; aud a long list of 
other agencies may prove the immediate or remote cause of the 
disease. It is believed that blondes of both sexes are the more 
frequent sufferers. But this observation may have been suggested 
by the circumstance that in the light complexions the symptoms of 



ACNE. 323 

the disease are more conspicuous and disfiguring. It certainly seems 
that young brunettes, with thick skins and abundant growth of dark 
lanugo hairs, furnish the most obstinate cases. 

The distinct cause of acne is the mechanical irritation set up by the 
inspissation of the secreted contents of the gland. The next efficient 
cause is perversion of the glandular function, in consequence of which 
the secretion is changed in character. 

Pathology. — The microscopical appearances are briefly those of an 
inflammatory process with exudation involving the peri-glandular 
tissue of the sebaceous glands and hair-follicles, and that about the 
common excretory duct. There is the usual vascular engorgement, 
the multiplication of protoplasm within and without the focus of the 
phlegmon, its metamorphosis into pus often mingled with blood, the 
destruction by suppuration of the sebaceous gland, and often the 
preservation of the hair-follicle though the latter may also be 
involved in the destructive process. According to Kaposi, there is no 
question that the first stage of the disease is always an anomalous 
performance of secretion or excretion in the sebaceous gland. Visible 
cicatrices rarely result, unless the destruction of the elements of the 
derma surpasses the original limits of the gland itself. Where 
suppuration does not occur, there is generally relief of tension by 
extrusion of the inspissated gland-contents and resorption of the 
plastic or fluid exudate in the periphery. 

Diagnosis, — The typical facies of acne vulgaris is readily recog- 
nized by the characteristic features already described. The reddish 
papules, pustules, comedones, and "lumps" in the skin of the face of 
a young subject ; the evident involvement of the sebaceous glands ; 
the history of a chronic affection destitute of itching and quite 
unscratched ; the occasional blood-crusts where lesions have been 
squeezed or incised, are all significant facts. The pustular syphilide 
of the face is not only to be differentiated by its share in the history 
of au infectious disease, but by the occurrence of characteristic crusts, 
its selection by preference, of the regions about the nose and mouth, 
its evolution in groups, and its sequelse in the form of superficial or 
deep ulcerations. Nevertheless, and this is a matter of prime 
importance as regards diagnosis, simple acne is exceedingly common 
in syphilitic subjects. The iodide of potassium is so largely adminis- 
tered for the relief of syphilis, and in so large a majority of cases 
induces its artificial acne, that the latter eruption often precedes the 
evolution of the macular syphilide, and also with surprising frequency 
masks the latter by a commingling of lesions. Simple acne is 
common also among those who are veterans of syphilis. Acne does 
certainly at times resemble variola, and cases of the former have 
actually been mistaken for the latter. In most instances, the absence 
of fever and a brief delay will soon put an end to any doubt. 

Treatment. — Acne is an entirely remediable disease in every case 
properly managed from the first. Scars of ancient ravages of the 
affection are, it is true, indelible ; but even these are smoothed down 



324 DISEASES OF THE SKIN. 

in the progress of time, so that they become yearly less conspicuous 
and disfiguring. 

An important consideration, at the outset of treatment of a patient 
affected with acne, relates to any local or internal medication which 
has been previously employed. A very large proportion of all 
patients first claim the attention of the physician after ingesting drugs 
or making topical applications which have decidedly aggravated the 
original trouble. With or without the advice of others, such persons 
have often been engaged for months iu swallowing the iodide of 
potassium, "red clover," and various nostrums calculated to "drive 
out" the disease; or in rubbing over the skin equally noxious pro- 
prietary substances. In every such instance the skilled physician 
should delay active treatment of the affection until the artificial acne 
has subsided, and the real condition of affairs cau be clearly recog- 
nized. The patient should be directed to discontinue his or her 
former practice, to bathe the affected part in hot water at night, and 
after it is dried to apply any bland unguent. By these simple 
measures alone, many cases can be very greatly improved, and some 
completely relieved. Their simplicity should commend them to 
every reader of these pages. It is a good thing to know what not 
to do. 

The constitutional treatment of acne rests for its success upon the 
discovery of the cause of the disease. Many cases certainly require 
uo such management, being entirely relieved by local treatment only. 
A thorough investigation of the habits of living, food, diet, bathing, 
occupation, and bodily functions of the patient, such as is described 
iu the chapter devoted to General Diagnosis, is essential at the outset. 

Since dyspepsia and constipation are frequent causes of the disease, 
it is necessary to correct these when present ; also any conditions of 
acidity of the stomach, distention of the transverse colon (Jewell), 
or marked anaemia. 

Some modification of Startin's acid mixture, such as the following, 
will be found suitable for many cases : 

R. Magnes. sulphat. 3ij ; 64' 

Acid, sulphur, dil. . f'3ij ; 8 

Sodii chlorid. 3j ; 4 

Ferri sulph. gr. v; 33 

Cardamom, tinct. co. f3j I 4 

Aq. dest. ad f J viij ; 256 M. 

Filtra. 

Sig. A tablespoonful iu a tumblerful of water before breakfast. 

Other cathartics, saline and alterative, will often prove serviceable. 
It is rarely found necessary to resort to arsenic, although this metal 
is highly recommended in acne papulosa, by both Duhring and 
Taylor. The internal employment of ergot in full doses for the relief 
of acne, as suggested by Denslow, has, without question, been 
frequently followed by excellent results. Cod-liver oil, iron, the 
mineral acids, and the bitters will prove valuable in chlorosis and 



ACNE. 325 

cachexia. The sulphide of calcium, iu quarter of a graiu (0.016) 
doses, is of decided benefit in obstinate cases. 

Glycerine in teaspoonful to tablespoonful doses three times daily 
has also proved valuable (Gubler). The mineral waters, Hathorn, 
Hunyadi Janos, oftener Racoczy or Kissiugen, a tumblerful before 
breakfast, are exceedingly valuable in cases of habitual intestinal 
torpor. When there is an acid form of dyspepsia, the rhubarb and 
soda mixture, or the acetate of potassium in half drachm doses (2.), 
will be serviceable. 

Temperate gratification of the sexual instinct in a happy marriage 
is couducive to good results ; and such a condition should generally 
be recommended as favorable for the future of young adults. 
Uterine disease should receive proper treatment when such compli- 
cation exists ; and this, far less by topical applications, than by 
attention to the general health, as the patients of this class are more 
often chlorotic young women with menstrual derangements, leading 
sedentary lives, or overworked at the school-desk, the sewing- 
machine, or the shop-counter. The diet should be carefully regu- 
lated, and the rules of hygiene enforced. 

As to the former, hot breads and cakes, sweets, pastry, oat-meal, 
uncooked vegetables, and all alcoholic beverages should be scrupu- 
lously avoided ; while fresh cooked meats, fish, and vegetables, fresh 
fruits, and tea and coffee in moderation should be permitted. 

In all cases, whether previously treated or not, which have been 
purged of suspicion of an artificial element, the local treatment is of 
prime importance, and in the perfection with which its details are 
observed, lies the key to success. It is not the selection of one of the 
several remedies of the many advocated for the relief of the disease, 
nor yet the successive substitution of one for another to meet any 
transitory indications in each case, which conduces to the happiest 
result. It is rather the use of a single method of recognized value, 
and its skilful adaptation to the changing conditions of the disease. 

It is first necessary to evacuate the contents of all pustules, to 
express from the summits of papules where are the orifices of seba- 
ceous ducts, all densely inspissated plugs of sebum, and to remove 
any comedones which are present, by the aid of the comedo- 
extractor. For the purpose of opening the superficial and smaller 
purulent collections, the long needles used by gynecologists are 
decidedly preferable ; and for the larger and deeper furuncular lesions, 
a bistoury with a delicate and very narrow blade. A slight degree of 
skill will here repay the operator. Piffard's acne-lance is useful in 
this same connection as is also Volkmann's spoon as modified by 
Auspitz, which may be employed in removing pathological debris. 
By counter-depression with the fingers the whitish-yellow or blackish 
orifice of the duct may be detected, and at that point precisely the 
needle or bistoury should be thrust sufficiently deep to insure the 
removal of pent-up pathological accretions. Should blood flow in 
droplets from any of these slight wounds, it is rather to be en- 
couraged than repressed, as relieving the hyperemia and engorge- 



326 DISEASES OF THE SKIN. 

ment of the small peri-glandular phlegmon. In one or several 
sittings, all lesions requiring such interference should be carefully 
attacked, and immediately after each, preferably while the pus and 
blood are still oozing, the part is to be bathed for several minutes in 
water as hot as can be borne with comfort. For many reasons, the 
hour before retiring is preferable, though not always practicable, iu 
treating such cases, as then a bland ointment can be thoroughly 
applied and permitted to remain till the following morning. 

When one or several of such operations have completely relieved 
the skiu of its engorgement and retained inflammatory products, a 
systematic use at night, of the spiritus saponis viridis with hot water, 
should be for a time practised. Let it be noted here, however, that 
man}- eases which do not require the minor surgical operation 
described above, should be from the first treated in this manner. 
As the face is the most common seat of the disease, it may be, for 
the purpose of description, considered as the affected part. 

The patient is seated before a basin of water, as hot as can be 
tolerated with comfort, and with a pad of white flannel or soft 
sponge, bathes the face till the skin is thoroughly moistened and 
softened by the heated water and steam. From ten minutes to half 
an hour may be well employed in this way, and it is a fertile source 
of the improvement which follows. Then, while the face is still wet, 
all pustules which have formed are emptied, and a sufficient quantity 
of the spirit of green soap is poured over the flannel or sponge, and 
the face thoroughly scrubbed with it. Finally the surface is cleansed 
with a surplus of the water, carefully dried, and anointed with a 
sulphur ointment. 

Some range may be observed in the employment of the two articles 
named. Thus the spirit may be diluted with cologne or rose-water, 
one half or more ; or the soaps employed, in less imperative cases, 
may be the best toilet, Sarg's glycerine, or sulphur soap. The oint- 
ment, too, may be compounded by adding half a drachm to two 
drachms (2.-8.) of the flowers of sulphur to the ounce (32.) of cold 
cream or vaseline. In the morning, the face is to be washed with 
cold water. 

This operation of steaming, soaping, and anointing, is to be con- 
tinued, according to the severity of the case and the tolerance of the 
patient, nightly, twice in the day, or on alternate nights, till the face 
is free from papules and other inflammatory lesions. At this time 
it is usually unsightly, reddened, slightly tumid, and often mod- 
erately furfuraceous, but free from acneiform lesions. To the patient, 
it feels tense, slightly painful, and as if made of leather. This accom- 
plished, the spirit, or other preparation of soap may be for the 
time discontinued. The improvement which follows is marked and 
speedy; and usually quite satisfactory to the patient. When this 
is reached, a wider latitude of treatment is permitted. 

Gradually the hot ablutions may be withdrawn, and the use of 
lotions and ointments other than those containing sulphur, may be 
advised. The last-named substance, having the highest reputation 



ACNE. 



327 



in the disorders of the sebaceous glands, 
the lotions thus employed. 

Taylor 1 advises the following : 



a constituent of many of 



Sig. 



Sulphuris loti 3iij ; 12 

Camphorge spts. f^iij ; 12 

Sodse biborat. 3ij ; 8 

Glycerin. f£vj ; 24 

Aq. fontan. ad f|iv ; 128 M. 
Shake well and apply freely, leaving a thin film of powder 
over the face. 



Various combinations of sulphur with alcohol will be found useful. 
Thus Kaposi recommends a paste composed of : 



R. Sulphur, praecip. 
Spts. vin. rect. 
Lavand. spts. 
Glycerin. 



Sijss ; 

fSjiss ; 
rt^xx: 



M. 



Sig. To be spread over the face and retained during the night. Or, 



R. Sulphur, flor. 
Spts. sapon. virid. 
Lavand. tr. 
Peruv. bals. 
Camphor, spts. 
Bergamot. ol. 



3ijss : 
f3v; 

m; 

Tt\,xx; 
ttlxv ; 



Sig. To be applied over the face at night. 
Duhring recommends the following : 

R . Sulphur, prsecipit. 3ij ; 

Glycerin. f^ij ; 

Alcoholis f^j ; 

Aq. calcis fgj ; 

Aq. ros. fgij ; 

Sig. Shake the vial before using. 



33 



M. 



R . Hum. crisp, rad. 
Adipis 
Cerae flav. 



Occasionally the rumex ointment may be used with advantage 
as the basis of sulphur and other salves in acne. It is prepared 
according to the following formula : 

gix ; 288 

§vj ; 192 

IU 32 
Aq. pur. q. s. ; 

Wash and bruise the roots ; boil for two hours ; strain ; evaporate 
to four ounces (128.) ; gradually add the wax and lard in a melted 
state ; and stir till cool. 

The English hypochloride of sulphur, in ointments of the strength 
of those given above, and the sulphuret of potassium, half to one 
scruple (0.66-1.33) to the ounce (32.) of lotion or ointment are 
effective, but objectionable on account of their odor. 

Various cosmetic ointments will be found useful in superseding 
those described above, as the case progresses. Among these may be 
named, the oxide of zinc, the subnitrate of bismuth, and freshly 



1 Amer. Clin. Lectures, vol. iii. No. 10, New York, 1878. 



328 DISEASES OF THE SKIN. 

levigated calamine in the strength of from one-half to one drachm 
(2.-4.) of one or more of these substances to the ounce (32.) of cold 
cream, to which, as required, the tincture of benzoin, glycerine, oil of 
roses or bergamot, may be added in suitable proportion. 

For mild cases an excellent lotion is obtained by adding a drachm 
each (4.) of the simple tincture of benzoin and glycerine to four 
ounces (128.) of distilled water, to which, where a more stimulating 
effect is desired an ounce (32.) of cologne water or rectified spirit 
of wine may be added, or a scruple (1.33) of the sulphuret of potas- 
sium. The following is the formula of the "Oriental Lotion," 
according to Hebra : 

R. 



Hydrarg. chlor. corros. 


3j; 


4 


Aq. destill. 


•3iy; 


16 


Ovorum iij albumen 






Succi citri 


3iij ; 


12 


Sacchari 


5J; 


32 



M. 

The bichloride of mercury is very generally employed in the 
strength of from one-eighth to one-half a grain (0.008-0.033) to the 
ounce (32.) of emulsion of bitter almonds as a lotion; and the prot- 
iodide, biniodide, and ammonio-chloride of the metal are similarly 
applied in both lotions and unguents ; the first two, in the strength 
of from five to ten grains (0.33-0.66) to the ounce (32.); the last-named, 
in the strength of from half a scruple to a scruple (0.66-1.33). One 
should be careful not to make use of the mercurials at the same time 
with a compound of sulphur, lest a chemical combination occur by 
reason of which the sulphuret of mercury is precipitated upon the 
skin and produces the appearance of comedo. Heitzmann highly 
recommends the solution of Vleminckx. 1 

Kaposi recommends also mercurial plaster applied on strips of linen 
iu obstinate cases, for which may be substituted iodated glycerine, 
five parts each of pure iodine and the iodide of potassium to ten of 
glycerine, applied with a brush twice daily till from six to twelve 
applications have been made. 

Van Harlingeu's favorite prescription is one drachm each (4.) of 
the sulphuret of potassium and sulphate of zinc to four ounces (128.) 
of rose water. Fox applies half a drachm (2.) of chrysarobin to 
the ounce (32.) of collodion. Taylor advises five to twenty-five 
grains (0.33-1.6) of the iodide of zinc to the ounce (32.) of vase- 
line. Veiel employs the uncertain unguentum Rochardi : 



R . Hydrarg. chlor. mit. 9j ; 1 

Iodi. puri. gr. vij ; 

Leni igne fusis adde 

Ungt. rosae aq. 31J ; 64 



M. 



The use of caustics in acne, though recommended by several 
authors, should be discountenanced as quite needless. In extreme 



1 The formula is : 

Jjfc. Calcis, Sss; 

Sulphur sublini. Sj ; 

Aq. dest. Sx ; 

Ooque ad Svj [192.] deinde filtra. 
Si;;. " Vk'iniiiukx'.s Solution." 



ACNE ROSACEA. 329 

induration of the lesions, they may be rubbed with fine pumice-stone 
till the desired effect is produced. 

The powders employed in the milder forms of the affection, are 
finely powdered sulphur, which may be freely dusted over the face; 
and those compounded, in various proportions, of starch, rice-flour, 
zinc oxide, and the subcarbonate of bismuth. 

Finally Sherwell, Denslow, and others in this country report relief 
of acne in young male patients after the passage of the urethral sound 
and, in both sexes, by hot and cold water injections of vagina and 
urethra. 

Acne Rosacea. 

Acne Rosacea is a chronic disease of the skin, chiefly of the face, often devel- 
oped from, or associated with, the lesions of acne vulgaris, characterized 
by hyperaemic rnaculse, patches of diffuse, dull red erythema, telangiectases, 
inflammatory papules, or vegetating masses, which may attain the size of a 
hen's egg. 

It is usual to describe three grades of this disorder, also named 
Gutta Rosea, or simply Rosacea, which is most often displayed upon 
the nose, though it may also affect the cheeks, lips, chin, and, rarely, 
the lateral regions of the neck. 

Symptoms. — In the first grade, there is a more or less diffuse and 
uniform, pinkish or dusky, but transitory reduess, involving the ex- 
tremity of the nose and its contiguous parts, which may extend from 
this part in a somewhat symmetrical figure over the cheeks and chin. 
The parts give rise to little or no subjective sensation. Under the 
finger, the color disappears under pressure, the surface seems cool 
rather than hot, and the sebaceous glands are seen to be affected, as 
there is usually present either a seborrhoea oleosa or an accumulation 
of yellowish-white, moderately inspissated sebum in the patulous 
orifices of the gland ducts. When the redness has existed for some 
time, minute bloodvessels can be seen ramifying over the erythem- 
atous surface. 

This disorder varies greatly with the general condition of the 
patient. At times, it may be scarcely perceptible ; again after the 
stimulation produced by ingested food or alcohol, after mental excite- 
ment, a paroxysm of coughing or laughing, or exposure to external 
irritation, the lesions may be even conspicuously deforming. This 
may endure for months or years, and then disappear or be succeeded 
by the second stage of the malady. 

In this second grade of the disease, the reduess becomes permanent, 
the capillaries dilate passively and appear as conspicuous, tortuous, 
straight or anastomosing lines of reddish color about the nose, cheeks, 
chin, or forehead. 

Firm, purplish-red, painless, pin-head to pea-sized nodules or 
papules often rise from the erythematous surface, and either display 
minute superficial and tortuous bloodvessels in the integument by 
which they are covered, or project from a base about which such a 



330 DISEASES OF THE SKIN. 

telangiectasis has been very irregularly developed. The lesions are apt 
to be intermingled with those of eeborrhcea oleosa or acne vulgaris. 
When fully developed, this stage of the disease, though generally not 
productive of marked subjective sensation, produces an exceedingly 
conspicuous deformity. 

In the third stage, which is the most pronounced of the three, 
roundish, sessile, or pedunculated, lobulated or pendulous, firm, 
elastic, pinkish-red, bluish, livid, or violaceous vegetations, traversed 
by liner or larger networks of bloodvessels, slowly develop about the 
affected part of the face, chiefly the nose. These may be single or 
multiple, and, in the latter case, isolated, or so closely united as to be 
scarcely distinguishable from each other. The acneiform lesions seen 
in the second grade of the disease, may here also be apparent. In 
other cases, there is a uniform, symmetrical, and elongated hyper- 
trophy of all the soft parts of the nose, which may thus attain colossal 
proportions. It is these consequences of acne rosacea to which the 
term Rhixophyma 1 has been applied. 

The course of the disease is very slow, and in by far the largest 
number does not produce the exaggerated types of the second and 
third grades. The lesions may persist indefinitely as indolent symp- 
toms of the malady in any one of its stages, or, in the cases where 
there has been no new growth of vessels or tubercles, proceed to 
spontaneous involution. 

Etiology. — The first and second grades of acne rosacea are common 
in women either at puberty or near the period of the menopause, in 
those who are pregnant, or who suffer from utero-ovarian disease, 
frequent miscarriages, sterility, irregular performance of the menstrual 
function, and chlorosis. It is, however, seen in men of early and 
late adult life. In both sexes, it may occur in anaemic and asthenic 
states. In both, also, its association with dyspepsia and the immode- 
rate use of alcoholic drinks, beer, wines, and spirits, is a matter of 
common observation. According to Kaposi, the rosaceous nose of 
the wine-drinker is bright red; of the beer-drinker, cyanotic or 
violet ; of the spirit-drinker, smooth, supple, fatty, and dark blue. 
The new growth of vessels and tubercles, with the rhinophyma of 
the advanced grade of the disease, is much more common in men 
than in women. In those whose faces are bronzed by exposure to 
the weather, the telangiectasia condition of the cheeks rather than of 
the nose, is of frequent occurrence. Veteran sailors and soldiers are 
thus commonly affected. Persons who have frozen the nose or the 
cheeks on one or more occasions, are similarly liable to the telangiec- 
tasia development. Any externally or internally operating cause 
which tends to retard the capillary circulation in the superficial por- 
tion of the skin, is capable of inducing the result. It is at times 
conspicuously displayed in the mulatto. 

Pathology. — In the first stage of acne rosacea there is merely passive 

1 For a full discussion of this subject, consult a valuable paper by Hans Hebra. in the Viertelj. f. 
Derm. u. Syph , 1881, 4 Hft., p. 603, illustrated by cuts giving the gross and microscopical appearances 
of the disease. 



ACNE EOSACEA. 331 

hypersemia. The circulation of the blood in the superficial capillary 
plexus of minute vessels is retarded. Persistence of this condition 
for long periods of time results in paresis of the capillaries, with 
their consequent dilatation and hypertrophy, phenomena which char- 
acterize the second stage, the sebaceous gland disorder being a com- 
plication of the process. In the third stage, the nodules are found 
to be composed of new-formed gelatinous elements, which become 
formed by organization. According to Biesiadecki, there are also 
dilatation and hypertrophy of the sebaceous glands, with dilatation, 
hypertrophy, and new growth of the superficial vessels, and enlarge- 
ment also of those trunks which ascend from the corium. 

Diagnosis. — Acne vulgaris is distinguished from acne rosacea by 
the absence of telangiectasis, and of the hypertrophic growths which 
characterize the developed lesions of the last-named disease. The 
tubercular syphiloderm is recognizable by its tendency to ulceration 
and crusting, and by the entire absence of telangiectasis. When the 
tubercles of syphilis are limited to the extremity of the nose, and are 
unusually small in consequence of the influence of treatment, they 
often degenerate into characteristic, split-pea sized, irregularly cir- 
cular ulcerations, superficial in seat, and frequently isolated. They 
leave similarly shaped and sized, depressed cicatrices at the tip and 
neighboring parts of the nose. As the process is much more rapid 
than in acne rosacea, these lesions, considered in connection with the 
absence of telangiectasis, furnish the most significant diagnostic 
symptoms of the disorder, for they often occur late in the history of 
syphilis, in individuals of middle life, and in varying shades of a dull 
reddish color, circumstances particularly favorable for confusion re- 
garding the identity of the two diseases. 

A case of zoster from involvement of the superior maxillary 
branch of the trigeminus, with diffused redness of one side of the 
nose and efflorescence of vesicles over its tip and ala, certainly 
strongly resembles acne rosacea with pustular lesions. Here the 
painful character of the disorder, its limitation to one side, its transi- 
tory career, and its vesicular lesions are sufficiently characteristic. 

Lupus vulgaris, like syphilis, when occurring upon the nose, is to 
be recognized by the tendency of its papulo-tubercular lesions to 
ulceration and crusting, the absence of vascularity, and the frequent 
presence of characteristic cicatrices. Unlike syphilis and acne rosacea, 
however, the history of lupus vulgaris usually extends to early child- 
hood. Lupus erythematosus is yet more readily differentiated, as it 
is not only unaccompanied by vascularization and ulceration, but is 
characterized by scaling and symmetrical diffusion over much larger 
areas, commonly extending from the bridge of the nose well on to 
the cheeks. 

Treatment. — As far as there can be said to be any internal treat- 
ment of acne rosacea, it is that of acne vulgaris, but in neither dis- 
order can such be confidently described as effective in the dispersion 
of the local lesions. The treatment is that of the patient rather than 
of his disease. When alcohol has been in any degree productive of 



332 DISEASES OF THE SKIN. 

the local effects, the use of spirits, wines, and beer is to be inter- 
dicted; but as regards confirmed rosacea, this will prove to be of but 
little avail. The disease, when resulting from spirit-drinking, may 
persist after live years of total abstinence. 

The diet should be of the simple character described above as 
proper for the patient with acne. All imbibition of hot liquids, even 
tea and coffee in excess, should be restricted as tending to congest the 
bloodvessels of the face. Everything having the same result in the 
habits, occupation, or clothing of the patient should be, as far as 
possible, deprived of influence, as, for example, the wearing of tight 
collars and corsets, the working over hot fires, etc. 

All gastro-intestinal sources of mischief should be also, when 
practicable, set aside. In acne rosacea, even more than in acne sim- 
plex, dyspepsia and constipation are conspicuously effective factors. 
Here it is well nigh imperative that there be a daily evacuation of 
the bowels. 

The local treatment of the first grade of acne rosacea is substan- 
tially that of acne vulgaris. Stimulating lotions of green soap, 
alcohol, bichloride of mercury, or sulphur in connection with ablu- 
tions by hot water, are of the highest value. In addition, the various 
ointments containing sulphur, the mercuric oxide and iodides, and 
the continuous application of mercurial plaster should be employed 
if necessary. 

Van Harlingen reports rapid results from the application, several 
times in the day, of a lotion composed as follows : 

R. 



Sulpkuris prsecipit. 


3j; 


Pulv. camphorse 


gr. v ; 


Pulv. tragacanth. 


gr. x ; 


Aq. calcis | 
Aq. rosre J 


aafgj; 



32 



M. 



Fox, of New York, applies chrysarobin in traumaticine, half a 
drachm (2.) to the ounce (32.), but this should certainly be re- 
served for intractable cases, as it may have severe results. Even, 
however, after the production of these severe effects, the benefit 
secured may be appreciable for months after. 

When the diseased condition is that of the second grade, the indi- 
cation is the destruction of the superficial capillaries, as well as the 
removal of the other indications present. Hardaway, of St. Louis, 
was early in destroying the vessels by single or multiple puncture of 
each with a fine cambric-needle attached to the negative pole of a 
galvanic battery, with six to ten elements in the circuit. This is 
better than the knife, which has repeatedly failed. The operation 
may be regarded to-day as the established and effective method of 
removing all blemishes produced by dilated bloodvessels in this stage 
of rosacea. It is simple, readily executed, requires no anaesthetic, 
and is in many ways superior to all other methods, which now should 
be relegated to a second grade in the list as only to be proposed when, 
for any reason, electrolysis cannot be employed. The author has 



ACNE ROSACEA. 333 

operated in many cases, with the result of destroying the vessels 
completely without the production of a cutaneous cicatrix which, in 
the course of a few months, could be recognized by the unaided eye. 

For details of this simple and elegant operation the reader is re- 
ferred to the chapter on Hirsuties, where it is more fully described. 
For the cambric-ueedle may often be substituted with advantage a 
fine jeweller's brooch, annealed in the flame of a spirit-lamp. 

The vessels may be entered in one or several places, and the opera- 
tion repeated till the last thread-like evidence of their existence has 
disappeared. The number of cells brought into the circuit must be 
somewhat graduated to the requirements of each case and the 
locality of the skin operated upon. Fewer can be tolerated for the 
lip and alse of the nose than for the root of it, the cheeks, or the 
forehead. 

Next in value after this operation may be named : 

Brushing the part cautiously with solutions of caustic potash, ten 
to thirty grains (0.66-2.) to the ounce (32.) of water; and the local 
use of pure carbolic, chromic, pyrogallic, and glacial acetic acids, 
acetum cantharidis (Taylor), iodide of sulphur, and the pernitrate of 
mercury. Before any of these, however, is employed, an effort 
should be made to produce exfoliation, by spreading over the part a 
plaster made of green soap. Unna's mercurial plaster-mull is simi- 
larly applied. Kaposi highly recommends the solution of iodated 
glycerine employed by him in acne vulgaris (q. v.), which is painted 
over the part eight to twelve times daily for three or four successive 
days, and immediately covered with gutta-percha paper. 

Multiple scarification of all new growths after the manner of 
attacking lupous nodules ; erasion with the dermal curette, or 
Braun's spoon ; and surgical ablation or decortication of tumors by 
ligature and. knife, are also available. After any destructive attack 
upon the diseased portions of the skin, the soothing lotions, fomenta- 
tions, or ointments should be regularly applied. 

Prognosis. — A favorable prognosis can be established only in cases 
where the disease is presented in its mildest forms. In those com- 
plicated by marked telangiectasis and hypertrophy, the results of 
treatment are not in the highest degree encouraging. In spite of the 
most energetic procedures, the vis a tergo of passive hyperemia, 
involving often the deeper and unassailed bloodvessels, works its 
slow progress. For women, the future is in general more promising 
than in the case of men. With the most unfavorable prognosis, 
however, it is to be remembered that, after all, the disease is one of 
deformity rather than of physical discomfort. 



334 DISEASES OF THE SKIN. 

Sycosis. 

Gr. ovkov, a fig. 

Sycosis is an acute or chronic non-contagious inflammatory affection of the 
surfaces provided with relatively long hairs, in which the follicles and 
perifollicular tissues are involved in an exudative process, producing 
papules, pustules, tuhercles, infiltrated patches, and crusts perforated by 
hairs. 

Symptoms. — This affection, also termed Mentagra, occurs upon the 
face, involving one or both cheeks successively or simultaneously, 
the chin, upper lip, eyebrows, scalp, axillae, and pubes. It is, how- 
ever, almost always a disease limited to the region of the beard in 
men. In this respect it differs from acne and other disorders of the 
sebaceous glands of the face with which authors have sought to 
identify it, since not only is it as a rule strictly limited to the region 
of the beard, but the more hairy portions of the face of the patient 
are free from comedones, acne lesions, and other symptoms of a 
cutaneous disorder. 

When seated upon the upper lip the first symptoms may be a nasal 
catarrh ; elsewhere an eczematous attack may precede the onset of 
the disease. It may be ushered in with such acute symptoms as are 
found in the early stage of some of the forms of eczema, tumefaction 
accompanied by a sensation of heat and burning ; but often a few 
isolated and indolent lesions whose presence scarcely awakens atten- 
tion, are the first traces of the disorder. Soon may be recognized a 
larger or smaller number of discrete, flattened or conical, reddish and 
painful papules, tubercles, or pustules, whose anatomical seat is dis- 
tinguished as the hair- follicle by the penetration of each by a filament 
of hair. These lesions may persist, and when typically discrete and 
visible at the part where the hair makes its exit from the duct of the 
follicle, have suggested the appearance of the surface of the fig, 
whence the disease has its name. They are apt to occasion a burning 
and at times a decidedly pruritic sensation when, being picked or 
torn open by the fingers, the pus concretes into a crust at the base of 
the hair. In severer cases these lesions while not coalescing, are so 
closely set together as to form a patch of continuous infiltration. 
These patches may be weeping or crusted; in the latter case the 
crusts are apt to be small and numerous, each being limited to the 
shaft of a single hair, and leaving when removed a minute crateri- 
form excavation at the mouth of the follicle. 

Involution of several lesions may be followed by fresh crops, and, 
sooner or later, distinct patches of disease are thus formed. AVhen 
fully developed, the surface of the skin is reddened, swollen, infil- 
trated, and thickened; covered irregularly here and there with papules, 
pustules, crusts, scales, and often with excoriated surfaces. The dis- 
ease is apt to lapse into chronic conditions, usually as the result of 
improper treatment ; and in ancient cases the deformity is character- 
istic and totally unlike that produced by the vegetable parasites. 



sycosis. 335 

The hairs are usually fixed firmly in their follicles, but from those 
where active suppuration is in progress they may be plucked without 
occasioning much pain. In the cases which have been treated for 
years, the hairs are thin and decidedly lacking in vigor. There is 
no parasite to be discovered. 

In typical neglected cases of long standing, where the region of 
the beard is involved, an important clinical feature is the symmetrical, 
general, and uniform involvement of the entire surface. The picture 
of one cheek is very nearly that of the other. The thin hairs 
scarcely serve to disguise the reddened, tumid, painful surface 
beneath, displaying the several lesions of the malady. Furuncles, 
abscesses, cicatrices, vegetations, and eczema of the ears may compli- 
cate the process. It is occasionally acute in its course, but more 
often chronic and rebellious. A typically chronic and untreated case 
of the malady rarely terminates by spontaneous involution. 

The thinning of the hairs described above as a consequence of long 
persistence of the disease is far more characteristic of it than any 
distinct resulting alopecia. The latter, however, very rarely ocgurs 
but is then remediless. The same may be said of resulting cicatriza- 
tion, which is one of the very rarest of consequences. 

The absence of certain symptoms in this disorder is as significant 
as the presence of others. Adenopathy of the cervical glands is very 
rare, and when present should awaken suspicion of another malady. 
The disease when of longest persistence as to time, produces great 
unsightliness, but no deep-seated, subcutaneous, small- or large-nut 
sized nodules or tubercles, forming the " lumps" so characteristic of 
trichophytosis of the beard. It is a disease of chronic course, which 
may last for years and be characterized by relapses and aggravations, 
but it is entirely curable and it is only in neglected and badly treated 
cases that such persistence may be expected. 

Etiology. — The exciting causes of the disease are obscure. It is 
encountered chiefly among men after puberty, and these in all 
social conditions and grades of health. It is non-parasitic, non- 
contagious, and not transmissible by heredity. Shaving is not known 
to produce it. At times, the immediate cause of the disease can be 
recognized, as when the upper lip is constantly irritated by the dis- 
charge from a profuse nasal catarrh. One such patient was seen by 
the author two years after Hebra first assumed charge of his case. In 
others again, all the causes of eczema may be invoked in explanation 
of the result. 

A careful study of many cases, however, suggests that the hairs 
themselves are the aggravating causes of the disease and the sources 
of its peculiar obstinacy. In health the motions of the free shaft of 
the hair do not irritate the follicle in which it is set. In conditions 
of disease it is quite different. Each free hair operates like a lever 
upon the inflamed ring of tissue which encircles it on its escape from 
the follicle beneath, and this whenever by the touch of the hand, by 
the action of brushing, by currents of air, or by any agency what- 
ever, a movement is imparted to it. Every such movement must 



336 DISEASES OF THE SKIN. 

tease to a variable degree the surface beneath, already irritated; and 
when estimate is made of the hundreds of such movements to which 
cadi hair is subjected during a period of twenty- four hours, the 
relative importance of this apparently insignificant factor may be 
appreciated. 

Pathology. — The disease is due to an inflammatory process, which, 
whether originally follicular or peri-follicular in its seat, may extend 
unquestionably either toward or from the follicle. Sometimes the 
extraction of the hair is followed by a drop of pure pus, which 
exudes from the follicle; and the root-sheaths of the hair are seen 
to be altered in consequence of the circumscribed follicular abscess. 
At other times, the follicle itself is free from disease, and the exuda- 
tive process has evidently expended itself upon the peri-follicular or 
even the inter-follicular tissues, in which case the papillary layer of 
the derma exhibits the usual phenomena of hyperemia, infiltration, 
and multiplication of protoplasm, with abundant vascular dilatation. 

According to Robinson, the disease always begins as a peri-follic- 
ulaj- inflammation, under the influence of which transuded serum 
penetrates the follicle. Maceration and eventual destruction of the 
root-sheath of the hair result with the ultimate production of pus 
within and without the follicle. The pus, when the hair remains in 
the follicle, finds its way to the surface by breaking through the epi- 
dermis near the hair; occasionally exit is obtained between the shaft 
and the follicle-sheath. 

Diagnosis. — The most important consideration here is the distinc- 
tion between the parasitic and the non-parasitic forms of disease of 
the region of the beard, upon which naturally the microscope finally 
decides. Still the clinical features of the disease are quite distinct. 
The non-parasitic form is recognized (a) by the greater redness of 
the involved surface; (b) by the extension of the disease in advanced 
cases to larger areas of symmetrical involvement ; (c) by the more 
superficial character of the lesions, and (d) by the firm implantation 
of the hairs in their follicles in the earlier periods of the disease, 
and their relative freedom in all cases from fracture and relics in the 
form of stumps. The parasitic disease of the hairs is peculiar, in 
consequence of (a) decidedly less redness of the surface attacked ; 
(b) its frequent limitation to a circumscribed area, or to several such, 
irregularly dispersed over a large region ; (c) the peculiar " lumpy, 
tubercular, nodular, and uneven " characters of the patch, upon 
which Duhring has laid significant emphasis; and (d) the earlier 
loosening of the hairs in their follicles, as also of the occurrence of 
fractured hairs and stumps, exhibiting usually at the bulb unmistak- 
able evidence of the nature of the disease. The malady is often 
mistaken for syphilis, chiefly on account of its deformity, but the 
pustular syphiloderm is very much less chronic in its course, is never 
limited for years to the face exclusively, and, when long persistent in 
one locality, is characterized by ulceration and the production of very 
characteristic crusts. 

Eczema may complicate non-parasitic sycosis ; but typical instances 



sycosis. 337 

of the two disorders may be recognized by the occurrence, in the 
former case, of a discharging disease not usually limited to the region 
of the beard, characterized by a more intense itching, and with marked 
absence of the papulo-tubercular lesions described above. 

The lesions, moreover, in eczema are not invariably perforated by 
hairs. Erythematous eczema of the shaven face is reddish in color, 
and desquamates, after full evolution of the disorder, without pustu- 
lation. 

Treatment. — In all cases of sycosis, the essential and important 
step is the continual removal of the hairs which, as indicated above, 
are the chief sources of aggravation of the disease. This is best 
accomplished by shaving, an act which, though often painful at the 
onset, is soon well tolerated by the sufferer. The majority of patients, 
however, object to the removal of the beard, far more on account of 
the consequent greater exposure to view of the deformity induced by 
the disease (then no longer partly masked by the hairs) than on 
account of the distress occasioned by the operation. To these objec- 
tions there is but one response. The shaving is essential ; the defor- 
mity is rapidly reduced after its successful initiation ; the discomfort 
diminishes with each repetition of the process. For the disease in 
patients positively refusing to have the beard removed whose cases 
are so severe as to require it, the practitioner will do well to decline 
to be responsible. There is no limit to the tedious and obstinate 
course of the malady in the one case ; and in the other, the results 
are speedily satisfactory, often in the course of a few weeks. 

When there is much tenderness, pain, swelling, pustulation, or 
crusting, the hairs may first be clipped short, and a bland poultice 
of oil, elm-bark, or bread and milk applied. The practice in Vienna 
is to substitute for the latter strips of soft muslin or linen spread 
with diachylon ointment, and firmly bandaged over the cheeks, chin, 
or lips for from twelve to twenty-four hours, after which the razor is 
passed over the entire surface. 

The integument which thus becomes visible, is usually a reddened 
infiltrated area, with pustules, papules, pustulo-papules, and some 
crusts dispersed here and there over it. This is best treated by very 
hot water lotions, pure or alkalinized, after exit is given to all puru- 
lent collections; and then a bland ointment is to be applied at night, 
and a dusting powder in the morning. The subsequent treatment is 
largely that of eczema of equal grade of severity. In the more 
acute periods, the oleated lime-water, medicated with calomel or zinc 
oxide, half to one drachm (2.-4.) of either to the pint (512.) may 
often be employed with benefit; or for this may be substituted two 
ounces (64.) each of linseed oil, castile soap, and paraffine, to the 
pint (512.) of aqua calcis. Later, ointments may be used, particu- 
larly cold cream, to which either sulphur, the zinc oxide, or, less 
preferably, one of the mercurials may be added. Lotions of the 
mercuric bichloride, sulphur, alcohol, cologne water, or iodated 
glycerine, may be useful in stimulating any indolent patches of infil- 
tration. The treatment of these is indeed that of chronic eczema. 

22 



338 DISEASES OF THE SKIN. 

In Vienna, epilation is successfully practised for relief of the 
disease; and, by many, severer methods are employed, including the 
use of green soap, tar, cauterization with acetic and even nitric 
acids. Erasure with the curette is to be named in the same category. 
It is possible that these measures have been employed in much more 
aggravated cases than those commonly observed here; but as the 
disease is certainly curable in a majority of cases without having 
recourse to these heroic methods, they are to be regarded in the light 
of a dernier ressorU It is not necessary in the immense majority of 
non-parasitic forms of sycosis, either to epilate or employ caustics. 
By repeated and frequent use of very hot water, and the milder 
stimulants, with constant shaving, the desired result is always within 
reach. Shaving should be continued for nearly one year after all 
traces of the disease have disappeared ; and it is a point of some im- 
portance to substitute a continuously applied dusting powder for a 
fatty application, so soon as the skin will tolerate the persistent use 
of the former. 

Van Harlingen advises for acute cases a wash composed of half a 
pint (256.) of rose water, to which one drachm each (4.) of precipi- 
tated carbonate of zinc and oxide of zinc in powder have been added, 
with two drachms each (8.) of glycerine and dilute liquor plumbi sub- 
acetatis. Veiel recommends a solution of pyrogallol, one part to fifty, 
for painting over the part affected, followed in the day by emollient 
cataplasms, and in the night by diachylon or weak tannin ointments. 
Sycosis of other portions of the body is to be treated as described for 
the region of the beard. 

Internally, treatment is of minimum value, and when indicated, 
should be of the kind demanded by the wholly accidental constitu- 
tional condition of the patient. It is a matter worthy of special 
attention, however, to purge every previously treated case of all 
suspicion of an artificial element, by withdrawing for a proper time 
all internal medication. The disease is so disfiguring that many 
patients swallow the iodide of potassium, arsenic, and other deleterious 
drugs for months before consulting one who is wiser than they in 
these matters. Exposure of the face to dust, smoke, wind, and other 
sources of irritation should be for a time avoided. 

Prognosis. — The disease is entirely curable, and will, in the large 
majority of all cases, either disappear entirely or be very greatly 
improved by judicious treatment. The latter requires the personal 
supervision of the physician and close attention to details. 

Dermatitis Papillaris Capillitii. 

Under this title Kaposi describes a disorder characterized by pin- 
head sized, isolated, or confluent elevations of the surface, with inter- 
spersed pustules, which finally form cicatriform plaques over which 
the hairs are either clustered in tufts or totally absent. The pilary 
filaments are atrophied yet firmly fixed in their follicles, and suffer 
elongation or fracture before withdrawal. The disease is encountered 



sycosis. 339 

chiefly upon the nucha, occiput, and vertex. Papillomatous vegeta- 
tions, crust-covered, hemorrhagic, and with a foul-smelling secretion, 
sometimes form, and eventually retract into a sclerotic tissue. 

The author has seen and described two typical cases of this dis- 
order, 1 and each concluded with the production of a keloid-like, 
cicatriform, irregularly shaped, but circumscribed elevation of the 
surface. This feature is that by which it specially differs from all 
other sycosiform disorders. The disease seems to be due fully as 
much to inflammatory processes in the subcutaneous tissues between 
the unyielding pericranium aDd the thick scalp as to the derma 
proper, and is not, therefore, strictly speaking, a dermatitis. Punc- 
ture, for example, of one of the pin-head sized pustules, commonly 
gives exit to the usual quantity of pus; but pressure upon the scalp in 
the periphery will at once be followed by the appearance of a still 
larger quantity of similar pus, which evidently is expressed from a 
circumscribed subcutaneous abscess. When by such pressure the 
abscess cavity is emptied, it slowly fills with venous blood, and pro- 
duces a firm, semi-solid elevation of the surface, which subsequently 
undergoes sclerosis, and the starved hairs above behave in the manner 
well described by Kaposi. The papules and plaques are formed in a 
similar way, by the abundant supply of venous blood. The case of 
one of the author's patients (presented at the clinic) had been erro- 
neously diagnosticated by a surgeon as aueurismal in character. Punc- 
ture of all such semi-solid, cicatriform lesions is invariably followed 
by oozing of venous blood in abundance. The disease is chronic in 
character, particularly liable to relapse in crops of pilary or peripilary 
pustules and papules, and extends from nucha to vertex, curiously 
avoiding the frontal and temporal regions. Over the bald or par- 
tially bald keloid-like elevations there is seen, in some cases, a species 
of seborrhoea in the form of more or less adherent, fatty crusts, with 
occasional characteristic tufts of hairs. None of these hairs was 
invaded by a parasite, though repeatedly examined with the micro- 
scope with a view to such discovery. 

The disease seems to owe its special character to the anatomical 
peculiarities of its location. It occurs preferably at the points where 
the venous supply of the scalp is not only greatest, but in most direct 
connection with the large vessels beneath, and where an inflammatory 
process in the derma or subcutaneous tissues invites with readiness a 
pathological afflux of blood. Such a focus, limited beneath by the 
dense calvarium, and with the relatively thick scalp above, readily 
undergoes organization and sclerosis, the subsequent behavior of the 
hairs and hair-follicles being an accident of the process. 

Sangster (in a paper read before the International Medical Con- 
gress in London, 1881) described a pigeon's egg-sized tumor of the 
scalp, which Kaposi, who was present, recognized as a case of derma- 
titis papillaris capillitii. 

The method of treatment to be employed in this rare disease can 

1 See a paper on this subject by the author, published in the Journ. of Cutaneous and Venereal 
, vol. i., No. 2, p. 33. 



340 DISEASES OF THE SKIN. 

scarcely be described as established. The affected surfaces are first 
freed from all subcutaneous abscesses by puncture and expression of 
the contents. Then the patch is washed with hot carbolized water, 
dusted with boric acid or iodoform, and a compress, moistened 
with an antiseptic solution, such as corrosive sublimate wash, rather 
firmly bandaged over the part. When the pathological fluids no 
longer form under the scalp, the patch is best epilated, and anointed 
with a salve containing one drachm (4.) of precipitated sulphur to the 
ounce (32.) of scented vaseline, which may also be kept constantly 
over the part. When crusts form, they may be removed by sham- 
pooing with green soap. 

Generally, internal treatment is suggested by the constitutional 
condition of the patient, and this should often include cod-liver oil, 
the ferruginous tonics, and a roborant regimen. 

Impetigo. 

Lat. impetere, to rush upon. 

Impetigo is an acute inflammatory affection of the skin, in which discrete, 
roundish, and acuminate or globoid vesicles, of the average size of a coffee- 
bean, form and rapidly fill with pus, which, being set free after rupture of 
the lesions, desiccates in characteristic crusts. 

Hebra has distinctly stated that the pustular, cutaneous affection 
described by authors under the name Impetigo has no existence as "an 
independent disease. Unquestionably a long list of disorders hitherto 
described under this term have been, in fact, forms of pustular 
eczema; and there are good grounds for believing that the symptoms 
detailed below are not those of a disease having a special identity. 
The reasons for retaining the name given above and for assigning to 
it certain peculiar eruptive features, are based upon the simple fact 
that the latter, probably in consequence of the operation in a similar 
way of similar causes, reproduce themselves again and again, so as to 
exhibit the same clinical picture in different patients. With a larger 
experience, it must be admitted that the convenience of the name, 
impetigo, as descriptive of a group of cutaneous symptoms, is more 
and more apparent. 

Symptoms. — The disease is sufficiently common iu practice, being 
observed chiefly in children and young adults of both sexes. In 
such patients, one to twenty or more isolated and often widely 
separated minute vesicles or vesico-pustules usually acuminate, ap- 
pear upon the surface either simultaneously or in rapid succession 
occasionally after a slight access of fever. They are speedily trans- 
formed into split-pea sized or larger pustules, so rapidly, in fact, that 
often the early vesicular phase is not manifest, the lesions showing 
as minute pustules from the first. When fully developed, they are 
globular, yellowish-white in color, discrete, well distended with their 
puriform, rarely bloody contents, and projected clearly from the sur- 
face on which they rest. They may be surrounded by an erythema- 



IMPETIGO. 341 

tous areola, or be simply superimposed upon an integument of un- 
altered color. They may persist as such or burst, and their contents 
dry into a yellowish crust resembling honey, or into brownish-tinted 
concretions which adhere with firmness to the superficial and circum- 
scribed base, where a slight weeping can be determined. They are 
much more commonly observed upon the face, but are recognized 
elsewhere, always sparsely upon the trunk and extremities. The 
eruption is never in any sense generalized, its characteristic feature 
being the fewness of the lesions, which rarely exceed twenty in 
number, which are scarcely ever grouped, and which occur in 
capriciously selected locations. The subjective sensations are slight, 
and the eruption is more picked than scratched. It is common in 
dispensary and hospital patients ; and since these are often the vic- 
tims of neglect and the subjects of vices of nutrition, it has been 
considered the appanage of scrofula. But the disease is also encoun- 
tered in well-nourished and rosy-cheeked children. In the latter, 
when well cared for, the eruption proceeds regularly to its natural 
resolution, while, in the former, it is prolonged and often aggravated, 
thus attracting to a greater degree the attention of a physician. The 
pustules are never umbilicated, never seated upon ulcers, never fol- 
lowed by cicatrices, and are incapable of transmitting the disease to 
another individual. 

Etiology. — The causes of the disease are not clearly recognized, but 
there is some reason to believe that it originates exclusively in local 
irritation. It occurs rather at the age of childhood than in infancy 
and adult life, a period when the hands are first brought into habitual 
contact with the face ; and these are, quite suggestively, the two sites of 
election. The lesions are very rarely scratched, more often torn with 
the nails in picking, so that the crusts may be a little blood-colored. 
There is reason to believe that the habit of picking the nose and 
other parts of the face and body with unwashed hands, is the sole 
source of the mischief. In later life the habit of refraining from 
carrying the hands to the face when the former are soiled, becomes 
instinctive. Before this instinct is well established, that is in child- 
hood, the hands will convey to the head any particle of filth or dust 
with which they may have been brought into contact. 

Pathology. — The lesions have been examined microscopically by 
Duhring and others, who have thus been able to establish clearly the 
purulent character of the contained fluid. Plainly, each is but a 
distinctly circumscribed and superficial pea- to bean-sized abscess, the 
sources of the pus being the horny layer of the epidermis. 

Diagnosis. — In order to establish the identity of this affection, it 
is necessary to define its exact diiferences from eczema pustulosum. 
These are, first, the absence of infiltration of the tissues affected; 
second, the absence of itching; third, the failure of the lesions to 
form patches ; fourth, the isolation and wide separation, each from 
the other, of lesions distinctly pustular; fifth, the large development 
and rather persistent character of individual pustules; and sixth, 
after involution of the latter, the evident termination of the disease, 



342 DISEASES OF THE SKIS'. 

which dors not, as dues eczema in many cases, progress to form a 
freely discharging and crusting surface, the pustular being but the 
initial stage of a distinct disease process. Manifestly, however, an 
impetigo of the sort described is not incompatible with an eczema 
which is often originated by less irritating causes. 

In ecthyma, the pustules are much more formidable in appearance, 
in consequence of their size, depth, inflammatory base, areola, flat, 
dark, bulky crust, and erosive action upon the skin. 

From impetigo contagiosa, the disease is distinguished chiefly by 
the absence of the evidences of contagion. The lesions of the latter 
are also, at first, strictly vesicular, not vesiculo-pustular or pustular, 
there is often umbilication, and the pus is auto-inoculable. The lesions 
may also coalesce. 

Treatment. — The individual pustules are to be opened with a 
comedo-needle; the purulent contents gently removed by washing 
with tepid water and soap, and the floor smeared with any mild oint- 
ment, such as five grains to half a scruple (0.33-0.66) of ammoniated 
mercury to the ounce (32.) of cold cream, or the subnitrate of bismuth 
half a drachm (2.) to the ounce (32.), or the benzoated zinc salve 

Van Harlingen recommends, after the application of salve on bits 
of muslin, the covering of the whole with waxed paper. A dusting 
powder containing calomel may be substituted for the salve or cm- 
ployed afterward. The disease tends to spontaneous recovery, if the 
lesions are not irritated. When they are situated within reach of a 
child's tongue, which is constantly thrust out of the mouth to moisten 
them, they may linger obstinately, and require protection by flexile 
collodion. 

Impetigo Contagiosa. 

Impetigo Contagiosa is an acute, inflammatory, contagious disease, character- 
ized by the formation of multiple, usually isolated, flattened or slightly 
umbilicated, roundish or ovalish, split-pea-sized and larger, vesicles, vesico- 
pustules, or blebs, which terminate by the production of yellowish, slightly 
adherent crusts. 

The disease is also termed by Pontoppidan, Pemphigus Acutus 
Contagiosus Adultorum . 

In 1862, Dr. Tilbury Fox observed and described the disease now 
under consideration, to which he gave the name by which it is most 
generally recognized to-day. 

Symptoms. — The eruption, occurring in infancy, childhood, and 
early adult life, is often preceded by a febrile process, and appears in 
the form of rarely numerous, isolated vesicles, vesico-pustules, pus- 
tules, or bulla?, usually about the face, but also on the neck, buttocks, 
hands, or feet. In severe cases these are surrounded by an areola. 
The lesions are roundish, flat, have the average size of a split-pea, 
and become covered iu the course of a few days with dry, granular, 
straw-colored crusts, which adhere closely to the slightly reddened 
base on which they rest. Very superficial erosions are to be dis- 



IMPETIGO CONTAGIOSA. 843 

covered beneath, which become rapidly covered with epidermis. 
They occasionally coalesce, and their complete involution requires 
from a week to a fortnight. When of the dimensions of bullae, a 
pseudo-umbilication may be observed at the apex, produced solely 
by naccidity of the roof-wall, which is never tied down as in variola. 
The contents of the lesions are inoculable and auto-inoculable, the 
disease thus spreading from one member of a family to another, and 
also from one part of the body of an individual to another. The 
mucous surfaces are said to be occasionally invaded. The subjective 
sensations are mild, the itching being rarely severe. The disease 
runs a tolerably definite course, being usually at end in a fortnight. 
It may recur. Kaposi states that it is at all times accompanied by 
submaxillary adenopathy. 

Etiology and Pathology. — Kaposi, Piffard, and Geber have all 
described a microscopic fungus which they discovered in the crusts 
of the disease, but neither they, nor Tilbury Fox, nor observers who 
have succeeded them, have ever been able to demonstrate the existence 
of a parasite in the contents of the lesions. Plainly, a parasitic 
vegetation on the exterior crust can have no etiological significance 
in this connection. The eruption often occurs during convalescence 
from a more or less actively contagious disease. The antecedence of 
some fever in many cases is admitted by all observers. Duhring and 
Fox himself have seen it follow vaccinia ; and the former admits that 
some connection between the two seems probable. The author has 
seen it occur typically in four children, each of whom was convales- 
cent from varicella ; and in one interesting case, that of a young 
woman convalescent from confluent variola, the lesions sprang from 
an integument where the pigmentation of the scars of the last-named 
disease had not begun to disappear. 

Stelwagon, in 1883, 1 making a new study of the subject, reports 
only six cases out of eighty-eight observed by him following vacci- 
nation, and concludes that the disease is non-parasitic, but an acute 
specific contagious exanthem, with cutaneous lesions pursuing a 
definite career. 

Pontoppidan, in 1885, found, as had many before that date, only 
epithelial cells, blood-corpuscles, and detritus in the crusts, never 
any indications of a parasite capable of explaining the' etiology of 
the disease. 

Dewevre 2 reports a number of successful inoculations and auto- 
inoculations practised with the contents of the vesico-pustule, with 
finely powdered impetiginous crusts and with the products of scraping 
the subjacent erosion. He reports finding reticulated mycelial tubes 
of the thickness of three thousandths of a millimetre in the rete 
mucosum beneath the lesion. 

In 1884, the author succeeded in producing an almost typical 
vesico-pustule upon his left forearm by inoculation, all due precau- 
tions observed, with the moistened debris of crusts. This was done 

i Med. Recorl, Deo. 22, 1883. 

2 Arch, de Med. et de Pharm. Mil., Sept. 16, 1885. 



344 DISEASES OF THE SKIN 

in the Dermatological Clinic, the crusts being taken from typical 
lesions upon the face of a young girl inoculated while under obser- 
vation fiom the l<si,,ns of exactly similar character on the face of 
her twin sister. The lesion on the forearm produced a characteristic 
crust, which in seven days was also u>rd for the inoculation of two 
students then present at the Clinic, in one of whom there was no 
result, and in the other an abortive lesion. 

The disease is contagious, and its lesious inoculable and auto- 
inoculable; but whether it be a specific exanthem, or due to a 
purely local parasite, or other cause, must be regarded as an unde- 
termined question. 

Diagnosis. — Impetigo contagiosa is distinguished from impetigo 
by its frequent pyrexic symptoms; its flat, yellowish, superficial, 
friable crusts; its vesiculo-bullous rather than distinctly pustular 
lesions, and its contagiousness. In pustular eczema, there are itching, 
infiltration, profuseness of discharge, iudefiniteness of duration, 
coalescence of lesions, and extensive bulkier crusts. In varicella, 
the lesions are small, much more widely distributed over the body, 
and are vesicular only, never bullous. In pemphigus and herpes 
iris, the seat, character, and period of evolution of the lesions will 
suffice to establish the diagnosis. 

Treatment. — The crusts are removed and a salve applied consisting 
of cold cream or vaseline with from five to ten grains to the ounce 
(0.33-0.66 to 32.) of ammoniated mercury. 

Impetigo Herpetiformis. 

Impetigo Herpetiformis is a cutaneous disease of women, frequently compli- 
cating the puerperal state, characterized by the occurrence upon the skin 
and mucous membranes of concentrically grouped pustules, and by a 
febrile condition which usually terminates fatally. 

Symptoms. — Our knowledge of this rare disease is limited to the 
reports of thirteen cases observed in the Vienna clinic by Hebra and 
Kaposi ; one in New York, by Heitzmann; one by Pataky; and a few 
scattered cases recorded by others. Of the Vienna patients, twelve 
were women, and these usually in the puerperal state. Pin-head 
sized pustules, usually closely packed together in groups, filled with 
an opaque or yellowish-green fluid, are discovered upon the surface 
of the groins, navel, axillae, breasts, and other portions of the 
body. A dirty brownish colored crust is formed by the rupture or 
desiccation of these lesions, and about this, single, double, or triple 
concentric circlets of new and similar lesions appear in succession, > 
each series undergoing a similar process of involution. The erup- 
tion thus extends till the circlets from different foci of origin unite ; 
and extensive areas of the skin are involved. Beneath the crusts 
the skin is reddened, infiltrated, smooth, and covered with a new epi- 
dermis, moist as in eczema, or exhibiting a denuded corium. It is 
never in a state of ulceration. In the course of three or four months, 
the eruption is well nigh universal, the skin being swollen, shining, 



ECTHYMA. 345 

and crust-covered, or seamed with excoriations here and there sur- 
rounded by circlets of pustules. The lingual mucous membrane 
exhibits grayish, centrally depressed patches, well-defined in contour. 
Alternate rigors and febrile accesses mark the periods of recrudescence 
when new pustules form. Delivery seems to have no favorable 
eifect upon the course of the disease occurring in pregnant women. An 
endometritis with peritonitis was discovered, post-mortem, in a single 
case. Two women only, of the thirteen Vienna patients, survived ; 
and one suffered from a relapse after several weeks of improvement. 

The etiology and pathology of the disease are necessarily obscure, 
having in view the relatively small number of reported cases. 
Duhring describes a much milder malady of similar type, occurring in 
women not pregnant, and has latterly included impetigo herpetiformis 
in the list of diseases covered by the title, dermatitis herpetiformis ; 
but Kaposi, in the last edition of his treatise, refuses to admit any 
such reduction of impetigo herpetiformis to a class of other maladies. 
Robinson also has described a case supposed to represent one of the 
mild manifestations of the disorder. Kaposi is inclined to associate 
the disease with a pathological coudition of the uterus. Heitzmann 
thinks it related to pemphigus. Besnier and Doyon conclude the 
disease to have a septicemic origin. 

The diagnosis of the disease is between herpes, dermatitis herpeti- 
formis, and pemphigus. 

In herpes, the purely vesicular character of the lesions and the 
cyclical career of the disease indicate its nature. In dermatitis 
herpetiformis there is commonly a distinct multiformity of lesions ; 
and the subjects of the disorder are not, in such great preponderance, 
pregnant women. In pemphigus, the size of the bullae, and their 
distribution in other than concentric groups, will indicate the character 
of the disease. 

The treatment is conducted on general principles, including anti- 
pyretics, and the local employment of alkaline, or carbolated baths ; 
starch and other dusting powders ; anodyne, carbolated or simple 
salves; and a mixture of plaster and coal-tar. The uterus should be 
relieved of its contents. 

The prognosis is necessarily grave. 

Ecthyma. 

Gr. endvfia, a pustule ; kudvu, I burn out. 

Ecthyma is an inflammatory disease of the skin characterized by the forma- 
tion of few or many, large, discrete pustules, implanted upon a dense, 
deeply situated base, the pus of which dries into dark colored, firm, bulky, 
and attached crusts, beneath which there may be superficial ulceration and 
resulting scarring. 

Symptoms. — Attention has already been directed to the position of 
Hebra in denying the existence of iurpetigo au d ecythma as distinct 
diseases. Ecthyma is, however, entitled to separate consideration, for 



346 DISEASES OF THE SKIN. 

the clinical reasons whose Importance appears after a careful study of 
a few typical cases. 

The disease is characterized by the occurrence of one or several, 
roundish, bean- to rilbert-sized, yellowish or reddish pustules, which 
are the result of a distinctly circumscribed, inflammatory process, 
limited to the base of each lesion, or extending from it at the 
periphery in a diminishing hyperemia. This process is distinguished 
by the formation of an indurated phlegmon at the base of the pustule, 
which is converted into a loss of tissue involving the corium. The 
purulent or sanguinolent contents of the lesions dry in dark colored, 
thick, rough, adherent crusts, the color being somewhat dependent 
upon the quantity of the blood with which they are commingled. 
On the removal of this concretion, a minute, shallow, and circular pit 
is discovered, invading the true skin to various depths, and lined 
with a tenacious, puriform, and often blood-stained product. When 
carefully wiped clean, this solution of continuity, which really con- 
stitutes a minute ulcer, is seen to have a floor reddish or grayish in 
color, and indolently granulating. 

The pustules may be acutely or indolently developed, and be, 
when multiple, coincident or successive. They occasion rather a 
sensation of heat, burning, and pain, than of itching, the latter being 
usually more distinct when the lesions are healing under their crusts. 
Their formation may be preceded by mild general pyrexia. They 
occur at all ages and in both sexes, usually upon the extremities, but 
also upon every portion of the body. 

Etiology. — The causes of the disease are practically those of eczema 
and dermatitis (traumatism, heat, scratching, parasites, etc.), but these 
usually operate in excess, or in subjects affected with other diseases, 
such as anaemia, asthenia, struma, variola-convalescence, and men- 
strual disorders. Filth and neglect are most common aggravations ; 
in other words, that circumscribed cutaneous ulcer will be the angrier 
and the deeper, which occurs in the victim of any depressing disease, 
whose skin is scratched with nails begrimed with dirt, and is covered 
with the effete products of the excretory processes. The pus thus 
jDroduced may be in various degrees inoculable and auto-inoculable, 
as is the product of many inflammatory processes of similar grade. 

Pathology. — The pustule of ecthyma differs iu no respect patho- 
logically from the pustule of eczema or the pustule of impetigo, save 
in the severity of the exudative process by which it is produced, and 
in its limitation to the exact site of external irritation. By the ex- 
tension of that process to the corium, there is an actual loss of some 
of the elements constituting the papillary layer ; and the result is a 
cicatrix, which contracts as it grows older, and is, in milder cases, 
finally barely visible as a minute cicatriform punctum. One who 
frequently examines the skin of the entire body with care can usually 
detect the ancient sites of these lesions by their indelible though 
insignificant relic-. 

Diagnosis. — Ecthyma is liable to be confounded with the other 
pustule-producing exudative affections, but as the distinction between 



ECTHYMA. 347 

them is largely artificial, and based upon the severity of the inflam- 
matory process, there is small danger in the consequence. Kaposi 
well expresses the truth in his suggestion that there can be but little 
objection to the employment of the term ecthyma when it is desired 
to characterize precisely the pustular grade of any cutaneous inflam- 
mation at a given time. The pustules of variola are "ecthyma-form," 
and many of those seen in syphilis possess similar characters. But 
in each the history of the general affection should throw light upon 
the identity of the cutaneous disease. In the latter, moreover, the 
ulceration at the base of the lesion exhibits the pronounced features 
of the syphilitic ulcer in its secretion, floor, edges, base, crust, and 
career. 

The crust, in particular, of the flat pustular syphiloderm has 
the rupioid conical appearance which suggests the shell of the oyster, 
and its underlying ulcer is larger and deeper than in ecthyma. In 
the furuncle there is usually a central core ; in impetigo, the pustules 
are not deep-seated, and there is no ulceration at the base. In im- 
petigo contagiosa the crust is superficial, yellowish, firmly adherent, 
and the lesions are more numerous. 

Treatment. — The general treatment of patients affected with ec- 
thyma is a matter of some importance. A proper regulation of the food 
and hygienic surroundings is not to be neglected. Tonics are fre- 
quently indispensable, including iron, quinine, and strychnia. The 
destruction of any pediculi, and the cleansing of the skin by soap and 
water will often be sufficient to effect a great change. This is well 
illustrated in hospital practice, where the little patients rapidly im- 
prove after a bath, followed by inunction with vaseline, and a few 
substantial meals of a nutritious character. When the lesions are 
abundant, the treatment is in general that of pustular eczema. Crusts 
are to be removed after soakings with oil or fat ; and the floors of the 
former pustules, after washing with carbolated water, should be dressed 
with an ointment containing ten to fifteen grains (0.666-1.) of the 
ammonio-chloride of mercury to the ounce (32.) of lard. If the minute 
basal ulcers are sluggish, they may be, after careful cleansing, touched 
with a small swab dipped in a solution of the bichloride of mercury 
in the tincture of benzoin, one grain (0.066) to the ounce (32.) Car- 
bolic and boric acids or iodoform may be employed for the same 
purpose. ' For the salve mentioned above may be substituted one 
containing ten grains (0.66) of calomel, or half a drachm (2.) of the 
subnitrate of bismuth to the ounce of salve basis. 

In every case of the disease it is desirable to inquire whether any 
medicines have been ingested prior to the appearance of the eruption, 
since these may be responsible for the lesions. 

The prognosis is always favorable. 



348 DISEASES OF THE SKIN. 

Pemphigus. 

dr. -infrt, a bladder. 

Pemphigus is an acute or chronic disease of the skin, often characterized by 
febrile and other symptoms of constitutional disturbance, accompanied by 
the production of a series of pea- to egg-sized bulla?, irregularly distributed 
over the surface, and distended with serum or blood. 

Symptoms, — The cutaneous lesions in this disease are usually 
preceded by febrile symptoms; and the disturbance of the economy 
is declared in cardiac, respiratory, and gastro-intestinal derangements 
of function. The fever may be continuous, remittent, or inter- 
mittent, and is usually exaggerated just before the appearance of a 
fresh crop of blebs. 

The eruption first appears in reddish maculae of rather vivid hue, 
in the centre of each of which appears later a whitish elevation of 
the epidermis suggesting a wheal. Either upon these or unaffected 
points of the skin, tense, well-rounded bullae subsequently form, 
varying in size from a pea to a hen's egg and even larger, and in 
number from three to six only, to a hundred and more. They are 
usually irregularly distributed (Pemphigus Disseminatus), but may 
be clustered in groups, or very rarely be found the younger encircling 
the older lesions, so as to form a circinate appearance (Pemphigus 
Circtnatus) ; their contents are serous, bloody (Pemphigus ELemor- 
rhagicus), or later purulent, with color corresponding to these 
fluids. Whether ruptured or not, the involution of the lesion is 
accomplished by desiccation and crusting, the crusts being usually 
found to contain blood, pus, epithelial debris, and the exudate from 
the base of the bleb. Beneath such a crust a new epidermis forms, 
which is usually violet, purplish, or bluish-red in color, and, later, 
displays a brownish pigmentation which may for several weeks 
survive the disease. 

Occasionally the affection occurs with very mild and even insig- 
nificant phenomena (Pemphigus Benignus). There may be no 
fever, and a very few blebs appear ; in some cases but a single lesion 
can be seen (Pemphigus Solitarius). In other instances, the fever 
is intense ; the eruption abundant ; the skin (edematous, painful, 
pruritic, excoriated, and the underlying lymphatic glands enlarged. 
This general condition with exacerbations and remissions may persist 
for months, and the eruption then disappear never to return or to 
recur, as it often does, in the future. 

The term Pemphigus Vulgaris is applied to the more common 
clinical forms of the malady, but it is also employed generically by 
many authors to include all varieties of the disease. Pemphigus 
Diutixus designates that pemphigoid eruption in which the charac- 
teristic lesions follow each other with rapidity, fresh bullae appearing 
each day. Fortunately, all forms of the disease are relatively rare. 

The lines technically drawn between many conditions of disease are 



PEMPHIGUS. 349 

quite artificial, however useful aud uecessary for systematic study and 
classification. Clinically, many of these distinctions disappear. This 
is especially true of the varieties of pemphigus. Between the benign 
processes just considered and the grave form of pemphigus foliaceus 
described in another chapter, several intermediate gradations can be 
observed, and even the most benign may at times unexpectedly assume 
the most malignant phases. Pemphtgus Malignus is a name given 
generally to those intermediate varieties of the disease, most of which 
are distinguished by persistent and prostrating fevers; cachexia, 
especially in infants; the occurrence of diphtheritic patches upon or 
about the lesions, with infiltration of the derma and slough of its 
superficial layers ; or extensive crusting, and even subsequent ulcera- 
tion. A form is described by Hebra and Kaposi, in which vegeta- 
tions and fungosities rise from the base of the blebs. Pemphigus 
Pruriginosus is another grave form of the disease, in which the 
lesions give rise to an intense pruritus, under the scratching induced 
by which they are torn, excoriated, and commingled with the crusts 
and exudations of an artificially engendered eczema. Several of 
these malignant and intermediate forms may terminate fatally. 

In all varieties of the disease, the lesions may be, exhibited upon 
the mucous membrane of the accessible outlets of the body. 

An important distinction, which has been established only within 
late years, should be made between acute and chronic pemphigus. 

Acute pemphigus occurs in adults, children, and infants, more fre- 
quently among the very young. It may be epidemic in hospitals 
and other public institutions. With or without an antecedent febrile 
movement, the blebs may appear before birth or within a fortnight 
after, in infants which are either well nourished or cachectic, more 
often the latter. In favorable cases, the evolution of the disease is 
completed in three or four weeks. Any part of the body may be 
affected, but, what is important from a diagnostic point of view, the 
face, hands, and feet are often exempt. The conjunctiva and mucous 
lining of the mouth may, however, become implicated. In some 
cases the pemphigus may be of hgemorrhagic type. Underneath the 
lesions, the rete is exposed, and has a reddish, glistening look. The 
termination may be fatal. Acute pemphigus of adults is still rarer. 
As in the case of infants, there may be marked febrile antecedents 
and systemic disturbance. The eruption of pea- to large nut-sized 
bullae may be sparse or abundant, covering in cases the entire body, 
and attacking the mucous surfaces. The vesicles or bullae may be 
tense, flaccid, and filled with clear, serous, or puriform contents. 
Beneath may be seen a smooth, raw, mucous layer or a diphtheritic 
exudation. According to Weyl, Bulkley's Herpes Gestationis is an 
example of acute pemphigus adultorum. 

Chronic pemphigus exhibits the greatest variation both as to its 
symptoms and the period of their efflorescence. There may be a 
week or month of immunity, followed by benign relapses, or by 
malignant and rapid recurrences. The bulla? may form upon an 
unaltered or deeply hypersemic skin, in all sizes from a pea to an 



350 DISEASES OF THE SKIN. 

orange, invading the skin and mucous surfaces including the vagina, 
the lesions at the base exhibiting the several features described above. 
The eruption is rarely generalized, and throughout not more than 
half a dozen Lesions may be at any one moment visible upon the 
surface of the skim The contents may be removed by evaporation, 
absorption, or rupture, leaving a crust whose color is largely deter- 
mined by the contents of the bleb. 

Etiology. — The causes of pemphigus vulgaris are so obscure that 
they may be said to be unknown. The disease is more frequently 
encountered in infancy and childhood, because, it would seem natural 
to conclude, the powers of resistance at a tender age are inferior to 
those of a maturer epoch. The disease is in general observed in 
debilitated patients, who are variously described as suffering from 
"nervous prostration," "mental worry and exhaustion," u neuras- 
thenia," " general debility," visceral disorders, and impairment of 
nutrition. Occurring in a vigorous, rosy-cheeked, strong-limbed 
adult, the disease would certainly be regarded as a curiosity. It is, 
therefore, safe to conclude that those states in which there is marked 
impairment of bodily vigor are particularly favorable to the develop- 
ment of the disease. 

Kaposi relates one case in which the disease seemed to be inherited, 
as the patient's mother, sister, mother's brother, and some of the 
children of the latter had been affected with the malady. While, 
however, this author admits such association of nervous disorder 
with the disease as occurs in hysteria and pregnancy, he concludes 
that there is little if any etiological significance in the fact. I have, 
however, observed one case in an adult where pemphigus of typical 
appearance occurred after mental depression, which was so greatly 
increased by the appearance of the exanthem as to lead to suicide. 

There is good reason to believe that, at least in some of its forms, 
the disease is contagious. The bullous lesions, however, seen in 
syphilis, lepra, and other similar disorders, should not be here 
included. 

Pathology. — Kaposi and Weiss found anatomical changes in the 
spinal cord of but one out of nine fatal cases of pemphigus. In this 
there was diffuse sclerosis, but the case was complicated with cancer. 
Jarisch discovered swelling of the processes of the ganglion-cells and 
interstitial fibrous deposits in a similar case. Dejerine and Leloir 
found changes in the peripheral nerves due to degeneration in a case 
of pemphigus. 

The contents of the bulla? of acute pemphigus were found to con- 
tain bacteria by Gibier in 1882. The microbe recognized by him 
was, when mature, arranged in chaplets, each containing a series of 
joints. His observations were confimed by Vidal and Roaser. Riehl 
in 1883, discovered both conidia and spores in the layer of epidermis 
beneath the lesions of an infantile pemphigus. Demme, 1 in 1886, 
found cocci both in the contents of the bulla?, and in the blood. 

1 Viertel f. Derm. u. Syph., 1886, p. 636. 



PEMPHIGUS. 351 

On the other hand Thin, of London/ after full trial of all methods 
of staining and cultivation now employed, had entirely negative 
results in his attempts to discover microorganisms in the contents of 
the bullae of pemphigus. 

Diagnosis. — From what has preceded it will be inferred that pem- 
phigus is a name given to a disease, and not merely to bullous lesions 
upon the surface of the skin. It is of some importance to remember 
this fact, as several authors have used the term in a purely descrip- 
tive sense, the fact being that bullae are manifestations of several 
disorders, including syphilis, lepra, pemphigus foliaeeus, herpes iris, 
and erythema multiforme. 

At the outset, consequently, the blebs of pemphigus can scarcely 
be differentiated from those of other diseases. It is necessary for its 
recognition that proper consideration be had of all the cutaneous and 
other phenomena present in the disease. In syphilis, such lesions 
are rare in the adult, and relatively more frequent in infants heredit- 
arily diseased. With the latter, the blebs are usually seen at birth, 
often upon the palms and soles, and are frequently superimposed 
upon an exulcerated base. The coexistence of mucous patches of the 
mouth, vulva, and anus with the evident polymorphism of the lesions 
and signs of grave cachexia, will usually indicate the nature of the 
disease. The cutaneous symptoms of such infants are improperly 
designated as pemphigus. Such an eruption is a bullous syphiloderm. 

In the bullae of lepra, there is usually coexisting cutaneous anaes- 
thesia, and the involution of the bleb is followed by a strikingly 
characteristic atrophic patch, usually pigmented and insensitive. In 
pemphigus foliaeeus, the extraordinary and usually generalized des- 
quamation which ensues, is sufficiently distinctive, though it must be 
borne in mind, as heretofore stated, that the several varieties of 
pemphigus may be transformed, the one into the other, by well-nigh 
insensible gradations. Among its graver forms susceptible of such 
transformation may be named, impetigo herpetiformis, pemphigus 
cachecticus, pemphigus diphtheriticus, and pemphigus pruriginosus. 

In herpes iris, the lesions are more vesicular ; much more tran- 
sitory; subject to a concentric arrangement and variation with respect 
to color; and are situated more frequently upon the extremities, 
especially the backs of the hands. The bullous lesions occasionally 
seen in urticaria and erythema multiforme, are to be recognized by 
the other characteristic symptoms of those diseases ; in the former, 
more particularly, by their intermingling with typical wheals ; and 
in the latter, by the location of the eruption, and its climatic or 
seasonal significance. Some of the reported contagious forms of 
pemphigus, epidemics of which have been described by Besnier, 
Hervieux, and other French authors, were possibly, as Duhring sug- 
gests, instances of impetigo contagiosa. This inference is sustained 
by the frequent allusion of the writers named to the "varicella-form" 
appearance of the lesions. 

i Lancet, May 30, 1886, p. 981. 



352 DISEASES OF THE SKIN. 

Some of the ingested medicaments are capable of producing bullous 
lesions, for example, the iodide of potassium ; and such a possibility 
should always be borne in mind when establishing a differential 
diagnosis. Scabies in infants and children is occasionally character- 
ized by the formation of blebs, in which case the other lesions present, 
as also a history of contagion and the discovery of the parasite, will 
point to the real nature of the disease. 

Lastly, the external application of cantharides, mezereon, the 
stronger acids, alkalies, and other chemicals may be followed by 
blebs produced either by accident or intention with a view to feigning 
disease. The intentional production of such symptoms is usually 
effected upon the anterior faces of the lower extremities, regions 
within easy reach of the right hand. Erysipelas and dermatitis 
calorica are also diseases in which blebs appear, always, however, of 
minor significance as compared with the other symptoms of disease 
present. The same may be said of the bullae which form upon a 
gangrenous integument. 

Treatment. — The internal treatment of pemphigus is a matter of 
importance, as will be suggested by even a brief consideration of the 
constitutional states in which it occurs. Mr. Jonathan Hutchinson, 
of London, Eng., in his valuable Lectures on Clinical Surgery, 1 dis- 
tinctly asserts his belief that "arsenic is a specific for the state of 
health upon which relapsing pemphigus depends." In many years' 
trial of this remedy, he .declares that, in his own practice, he has 
never recorded a single failure, though he makes exception, properly, 
of many infantile cases supposed to be syphilitic. The remedy is 
certainly a valuable one, but should be employed with the same 
caution and in accordance with the rules already prescribed in the 
chapter on psoriasis. Kaposi, however, declares that he has been 
unable to obtain favorable results from its employment. Iron, 
quinine, ergot, strychnia, and the mineral acids are certainly indicated 
in many cases, in conjunction with a particularly nutritious diet. 
Cod-liver oil and the malt preparations now in the market should 
not be neglected. 

Not infrequently the treatment should be directed to the relief of 
the anomalous performance of the sexual function in women, as the 
disease has been found to occur in the hysterical and chlorotic states 
sufficiently common as a result of such disorder. 

The local treatment of the lesions should consist, first, in a punc- 
turing of each bleb with a fine needle, in order to give exit to its 
contents, which should be carefully removed from the skin by the 
aid of cotton-wool. Then the parts are to be thoroughly enveloped in 
an inert dusting powder. When there is considerable pyrexia with 
heat and distress in the skin, the surface may be treated as in acute 
eczema, with oleated lime-water, containing also opium or dilute 
hydrocyanic acid in some such proportions as those already detailed. 

1 London, J. & A. Churcliill, 1878, p. 49. 



CUTANEOUS HEMORRHAGES. 353 

The ordinary lead and opium wash, with or without the addition 
of the oxide of zinc, will also answer a good purpose. 

In Vienna, the continuous hot-water bath still enjoys the highest 
favor. Kaposi has kept one patient day and night for eight months 
with his body thus immersed, to the great advautage of the latter. 
Such a course is often impracticable outside of a large hospital ; but 
the author has, in two cases of grave pemphigus, employed the con- 
tinuous hot-water bath in private houses, with the happiest results. 

Prognosis. — The prognosis in mild cases of pemphigus, though 
much less grave than in the malignant forms of the disease, should 
always be formulated with caution. Unlike several of the diseases 
heretofore considered, the aifection is one not frequently encountered 
in persons of fair general health. The constitutional condition of the 
patient must be carefully considered; nor should it be forgotten that 
the disease is not only one liable to relapses, but also one in which 
the graver may succeed the more benign manifestations. A flaccid 
summit of the bleb, sanguinolent or ichorous contents, an abundant 
efflorescence, and a rapid succession of new after the involution of 
more ancient lesions, are in general unfavorable symptoms. The 
same may be said of degeneration of the floor of the bleb, after 
rupture and discharge of its contents. 



CLASS III. 

HJEMOEBHAGES. 
Cutaneous Haemorrhages. 

Cutaneous Haemorrhage is characterized by the issue of a part or all of the 
constituents of the blood from the cutaneous or subcutaneous vessels, 
with and without rupture of the vascular walls. 

Haemorrhage into the skin may be active or passive, idiopathic 
or symptomatic, and may vary greatly in extent. It may be limited 
to but a small area of the integument, or may be symmetrical and 
universal, or coexist with similar blood extravasations in the mucous 
membranes, and the investments and parenchyma of the viscera. 
It may result from undue intra- vascular pressure, as in violent 
effort with extraordinary demand upon the circulatory system. It 
may occur with a normal intra-vascular pressure when there is 
lessened extra-vascular atmospheric pressure, as after ordinary exer- 
tion in high altitudes. It may result from disease of the vascular 
walls, as in malnutrition. It may occur after traumatism of the 
latter, or by diapedesis through the walls of uninjured capillaries. 
It may result also from lack of Support of the vessels due to various 
disorders of peri-vascular tissues, as in the case where the epidermis 

23 



354 DISEASES OF THE SKIN. 

is artificially removed, or where au abscess cavity is evacuated of pus, 
and the sac immediately fills with blood. 

Idiopathic haemorrhage into the skin and neighboring tissue is 
usually the result of traumatism, and accomplished through rent of 
the vascular wall. The discolored patches which result from con- 
tusions of the surface of the body are illustrations of this condition. 
Examples of symptomatic cutaneous haemorrhages are to be found 
in the course of such general diseases as septicaemia and variola, 
and of such cutaneous disorders as herpes, pemphigus, and erythema 
multiforme. 

Bullae ELemorrhagicle are globoid, bean- to egg-sized eleva- 
tions of the epidermis, filled with a sanguineous or sero-sanguineous 
fluid, giving such lesions a reddish, brownish, or purplish shade. 

Ecchymomata are nut- to egg-sized, and even larger, firm or 
fluctuating, flattened or elevated tumors, filled with blood, and having 
a cutaneous envelope. 

Ecchymoses are small coin- to palm-sized, and even larger, light 
red to dark purplish, irregularly shaped, macular colorations of the 
skin, not fading under pressure, and due to circumscribed cutaneous 
haemorrhage. 

Petechia are pin-point to small coin-sized, light red to dark 
purplish macular colorations of the skin, not fading under pressure, 
and due to circumscribed cutaneous haemorrhage. 

Vibices are linear maculations of various lengths, due to the 
diffusion in the skin of extravasated blood in the form of streaks or 
bands. They are often commingled with petechias and ecchymoses. 



Purpura. 

Gr. -rropQvpcog-, purple. 

Purpura is a disease characterized by the appearance in the skin, of reddish- 
purple or livid maculae, varying in size, usually not clustered, and not 
wholly disappearing under pressure, which may be associated with systemic 
symptoms. 

Some confusion has existed in connection with the term, Purpura, 
in consequence of the fact that it has been employed indiscriminately 
by authors in the designation of both symptoms and diseases. The 
following disorders are commonly included under this title : 

[A.] Purpura Simplex. 

In this form of cutaneous haemorrhage, pin-head to pea-sized 
light red to dark purple petechia? and small ecchymoses, usually 



PDEPURA. 355 

multiple and symmetrical, of slow or sudden occurrence, appear upon 
various portions of the surface, chiefly over the lower extremities, 
and here doubtless by preference, because of the greater effect of 
gravity upon the column of blood. They usually awaken no sub- 
jective sensation, and may occur in persons of apparently unaltered 
health, though rigid examination will often disclose some facts having 
a bearing upon the etiology of the disease. The subjects of the dis- 
order are frequently asthenic, and complain of unwonted lassitude 
and malaise. The disease may last for a fortnight, and in exceptional 
cases be accompanied by a febrile rise of temperature. Lesions of 
this sort may be due solely to an ingested medicament, such as arsenic, 
salicylic acid (Freudenberg), or quinine. The author has seen the 
lower extremities completely covered with petechia?, induced by 
the ingestion of the iodide of potassium, a fact reported by other 
observers. 

Purpura Urticans 

is that form in wdiich there is an irritability of the skin sufficient to 
produce w r heals, urticarial lesions accompanied by itching in various 
degrees, which have the purpuric hue in consequence of circumscribed 
cutaneous haemorrhage. 

Purpura Rheumatica. (Peliosis Rheumatica.) 

This is a variety of purpura which has a striking analogy to ery- 
thema multiforme, and is probably an exaggerated form of some of 
the conditions recognized under that title. It is preceded by the 
usual febrile or other premonitory symptoms associated with arthritic 
pains, especially of the knees and ankles, which may become swollen, 
or be affected with an hydrarthrosis. In a few days, petechial to 
ecchymotic, light red to dark purplish maculations appear upon the 
extremities, trunk, or the entire surface of the body, fadeless under 
pressure, and usually with coincident relief of the arthritic paiu. 
The subjective sensations are ordinarily trivial. In a fortnight, the 
eruption may subside, its color undergoing the usual variations from 
greenish to orange and light yellow ; but relapses are common in the 
course of weeks, with recrudescence of the fever, return of the rheu- 
matoid symptoms, and progressive asthenia. Kaposi describes cases 
in which there was coincidence of purpura rheumatica with renal 
haemorrhage, albuminuria, and gangrene of the soft palate in conse- 
quence of its over-distention with blood. Cases are also on record 
where there were cardiac involvement and grave disorder of other 
viscera. According to Mackenzie, 1 the disease occurs in both sexes, 
more frequently in women however, and between the ages of twenty 
and thirty, though also at earlier periods of life. The purpuric 
spots observed by him usually made their appearance regularly in 
the afternoon or evening, sometimes daily, and often with several 

i Brit. Med. Journ., March 18, 1882, p. 383. 



356 DISEASES OF THE SKIN. 

days' interval, accompanied by pain, stiffness, and .swelling of the 
joints. The maculae were at first of a bright reddish hue, but 
became purplish by the ensuing day. The site of predilection was 
the extremities, but the eruption in his cases was sometimes more 
generalized. 

The lesions displayed this amount of symmetry : if they occurred 
on one extremity, upper or lower, they would generally be found on 
the other. As a rule, there were not profuse sweats, unless the attack 
occurred with rheumatic fever; the joint affections and pyrexia, 
though distinct, were not severe. Sometimes there was a certain 
amount of erythema accompanying the haemorrhages; often the 
eruption was purely haemorrhagic. The attacks were frequently very 
protracted, lasting even some months, and were liable to recur. 

The disease occurs in both sexes, though more often in young 
women, and is to a certain extent influenced by the changes of climate 
and season. Its diagnosis, in consequence of its marked characteris- 
tics, coincidence of petechias and ecchymoses with rheumatoid pains, 
is readily effected. Duhring calls attention to the danger of con- 
founding it with the macular syphiloderm, the lesions of which, 
however, fade under pressure. The prognosis is in general favor- 
able, though the disease may persist for long periods of time, and 
may, in rare cases, terminate fatally. 

[B.] Purpura Haemorrhagica. (Morbus Maculosus Werlhoffii.) 

This disorder, called also land-scurvy, is usually ushered iu with 
phenomena of a febrile character, accompanied by symptoms of 
general depression. Subsequently, ecchymoses appear upon the ex- 
tremities aud trunk, both spontaneously and at points where the 
integument has been specially subjected to pressure and friction. 
Usually petechias appear simultaneously upon the nasal, laryngeal, 
buccal, and other mucous surfaces, which may also be the seat of 
exhausting haemorrhages, resulting rarely in fatal collapse. A symp- 
tomatic fever is usually awakened. The disease occurs equally in 
the robust and feeble of all ages, and, though usually as a sporadic 
affection, it may assume an epidemic form. The disease is slow in 
its course, but commonly terminates favorably after the lapse of 
several months. 

The lesions commonly appear first on the upper extremities ; then 
over the trunk, and finally over the lower extremities. They are 
usually dark red or purplish in hue, varying in size from a pin-head 
to a bean, but may be of the size of the palm. 

It is distinguished from purpura scorbutica, or "scurvy," by the 
absence of distinctive premonitory symptoms of the latter disease, 
and its invariable occurrence among those suffering from improper 
alimentation, vitiated air, and lack of exercise. 



PURPURA. 357 



Purpura Scorbutica. (Scurvy.) 



This disorder is peculiar to those who are compelled to subsist for 
lengthened periods of time on improper food, more particularly that 
from which fruit and fresh vegetables are excluded; to respire a 
vitiated air ; and to endure such confinement as precludes the pos- 
sibility of duly exercising the body. The disorder is hence more 
common among sailors, prisoners, Arctic voyagers, and men similarly 
situated. 

The cutaneous lesions are, as in so many other forms of purpura, 
preceded by an almost characteristic sense of languor and depression. 
One or several joints may then enlarge. There may be, however, a 
distinct febrile action. 

The haemorrhages which result are quite like those of purpura 
haemorrhagica; and the cutaneous lesions are petechia?., ecchymoses, 
and painful ecchymomata, usually first appearing on the lower ex- 
tremities, which may fluctuate, open, and result in offensive ulcera- 
tions reaching to the bone. Simultaneously with the cutaneous 
eruption, the gums become involved, and show as tumid, haemor- 
rhagic, or ulcerative ■ fungosities, smeared with a dirty yellowish 
secretion, and having a fetid exhalation. The subcutaneous connec- 
tive tissue, muscles, fasciae, and viscera become also involved. The 
disease is accompanied by febrile and other general phenomena of 
asthenia, and, when the causes are persistent, results fatally. It is, 
however, remediable by proper treatment, though convalescence is 
usually tediously prolonged. 

Purpura Pulicosa 

is the result of the traumatisms produced by fleas, lice, and bugs. 
The lesions are punctiform, and due to the welling up of blood into 
the minute punctured wound, surrounded usually by an hypersemic 
halo which is the result of the irritation. When the latter fades, 
the centra] hemorrhagic point usually for a brief time persists. The 
disease is characteristically manifested upon the filthy skins of indi- 
viduals long bitten by bugs, and covered with excoriations and dark 
colored crusts, the result of scratching. Such cases are often pro- 
nounced scorbutic. 

The symptoms of cutaneous haemorrhage are also observed in 
other conditions besides those named above. Petechias and ecchy- 
moses are also in cases noted upon the lower extremities of the sub- 
jects of tuberculosis, cancer, and the plague. In Haemophilia, a 
disease occasionally of hereditary origin, and characterized by the 
facility with which trivial traumatisms of the surface are followed 
by incoercible haemorrhages, purpura may be the first signal of the 
predisposition. A young man with purpuric lesions of both lower 
extremities, and otherwise in apparently good health, lately presented 
himself at the Dermatological Clinic for the relief of the difficulty. 



358 DISEASES OF THE SKIN. 

There was at the time no suspicion of haemophilia, but two weeks 
later, as the result of a vaccination, he bled continuously for eight 
days. 

Pathology. — Many cutaneous haemorrhages, not resulting from 
traumatism, however manifestly and immediately due to morbid 
conditions of the vessels, are by many authors believed to have a 
neurotic origin. Purpura hemorrhagica, for example, in conse- 
quence of the frequent absence of lesions of the vascular walls suffi- 
cient to explain its phenomena, is by Wagner, Henoch, and others 
explained by supposing either abnormal excitation of the sympa- 
thetic system, or paresis of the vaso-motor centres. Cavalier 1 reports 
a case of purpura alternating with paralytic symptoms. The fre- 
quently symmetrical disposition of the lesions has received a similar 
interpretation. Tyrrell 2 reports cases induced by marsh-miasm, and' 
Satterthwaite, 3 of New York, a similar case, in which the eruption 
followed a chill lasting three-quarters of an hour. 

In all these eases, the haemorrhages occur chiefly in the derma, 
though often in the subcutaneous connective tissue, a fact well illus- 
trated by the drawings made by Variot 4 of sections of the purpuric 
skin of a patient dead of haemoptysis. In this case there was nu- 
merical diminution of the red corpuscles in life, as demonstrated by 
the hematimetre, without any change in their form, volume, or color. 
Inflammatory complications in these conditions are rare. The color 
of the several lesions induced is, without question, derived from the 
hsematine, which not only stains the environing fluids, but also the 
tissues themselves where the extravasation occurs, and appears, when 
absorption of the fluid portions of the clot has been accomplished, in 
the form of variously sized granules. In this way, the color-changes 
between red, orange, yellow, purple, and violet in the resolution of 
petechia? and ecchymoses are to be explained. The persistence of 
the pigmentations varies with the quantity of the effused blood and 
its seat. In mild cases, especially of lesions involving the upper 
half of the body, all traces of the haemorrhage may be removed in the 
course of a few weeks. Dark pigmentations resulting from purpura 
scorbutica, affecting prisoners at Audersonville during the late civil 
war in this country, are still, in some persons, perceptible upon the 
lower extremities. 

The explanation of the diapedesis of blood through the vascular 
walls by supposing changes to have occurred in the fluid itself, has 
been made by dial vet, Andral and Gavarret, and others. The pale 
and watery appearance of the fluid, the increase in the proportion of 
fibrine in the clot, the diminution in the number of the red blood- 
corpuscles, and the lowered specific gravity of the blood have all 
suggested this view. Kietschy has called attention to irregularity in 
the shape and metamorphosis of figure in the red blood-corpuscles. 

i Bull. Gen. de ThSrap., 1879. = Pacific Med. and Surg. Journ., June, 1876. 

3 Med. Gazette, Jan. 14, 1882, p. 14, cited by DnhrinK. 

4 Journ. do l'Anatoni. et de la Phys , Nov.," Dec, 1881, p. 520. 



PURPURA. 359 

Wilson, Fox, and others, again, have recognized lardaceous or 
inflammatory changes in the vascular walls, with embolism or 
thrombus in others. Watson Cheyne 1 discovered in a case recorded 
by Russell, some of the capillaries in the neighborhood of the haemor- 
rhages plugged with bacilli, and colonies of the same in the blood 
effused after rupture. 

Treatment. — The treatment of these various forms of cutaneous 
haemorrhage will clearly depend upon the nature of the cause in each 
case. In general it may be said that internally the use of ergot, 
of the chloride or other salt of iron, and of quinine is advisable. 
The oil of turpentine, the tincture of the muriate of iron, the acetate 
of lead, and dilute sulphuric acid, have all been employed at times 
with marked success ; at others, without ; in the treatment of these 
cases. Hypodermatic injections of Bonjean's ergotine, one part to 
two of distilled water, repeated every second day, have been speedily 
followed by favorable results. A generous diet, the use of wines, 
malt liquors, and even spirits, and strict observance of the demands 
of hygiene, are often essential methods of relief. 

In the way of local treatment, the gums often require an applica- 
tion of rhatany, one part of the extract to fifty or sixty of lotion ; 
or equal parts of the tincture of cinchona and tincture of myrrh, 
diluted as required. 

Rest in the recumbent position is advisable, and, if haemorrhage be 
actually in progress, the free use of haemostatics will be required with 
local application of ice. For those who are convalescent from systemic 
disorders accompanied by purpuric lesions of the lower extremities, 
resorption of the extravasated blood may be hastened by the local 
application of stimulating spirit lotions with friction ; and the pres- 
sure of the blood column may be partly relieved by elastic bandaging 
of the extremities. 

The prognosis has been given, as far as might be, in connection 
with each disorder named. 

i Brit. Med. Journ., Sept. 1, 1883, p. 416. 



360 DISEASES OF THE SKIN 



CLASS IV. 

HYPERTROPHIES. 

1. Of Pigment. 

Lentigo. 

Lat. lens, a freckle. 
Lentigo is that condition in which occur pin-head to bean sized, yellowish to 
brownish, circumscribed, and usually multiple maculations of the cutaneous 
surface, due to an excessive deposit of pigment, most often seen on the face 
and dorsal surfaces of the hands. 

Symptoms. — This condition, termed also Ephells, is due to exces- 
sive and irregular deposit of pigment in the skin, producing the 
pin-head to bean-sized spots of circinate or irregular outline, 
frequently grouped and even confluent, which are commonly desig- 
nated as " freckles." They are most frequently seen symmetrically 
distributed on the parts of the body ordinarily exposed to the light 
and heat of the sun and atmospheric influences, such as the face, the 
neck, and the backs of the hands in persons of both sexes. In those 
whose bodies are to a greater extent similarly exposed, they occur 
upon the chest, the back, and over the extremities. In other indi- 
viduals, they may be seen upon parts not thus exposed, such as the 
penis, the scrotum, and the inner faces of the thighs, a fact which 
indicates that they are not always the result of the operation of the 
agencies noted above. They vary in color from light yellow, salmon, 
and red to the deepest brown ; and are most noticeable in persons 
having red hair and a delicate skin. They occur rarely in infancy, 
partly, perhaps, on account of the infrequency of out-door exposure 
in tender years ; and are usually seen first about the age of six to 
eight years. They are commonly observed in mulattoes, individuals 
of a race particularly disposed to the anomalies of pigment distribu- 
tion. Once developed, the lesions may persist through life without 
marked alteration ; or fade with each recurrence of the season of 
winter ; or, in milder cases, entirely disappear. They usually share 
in the atrophic changes of old age, and, when persisting to that 
period, may then spontaneously disappear. They are not the source 
of subjective sensation. 

Etiology. — Freckles are, without question, produced and aggravated 
at times by the action of the light and heat of the sun, as a common 
experience declares ; but it is evident that these forces must act upon 
a susceptible skin. Of a hundred sailors exposed in precisely similar 
situations on a long cruise, some of the number will be uniformly 
" tanned," and others deeply " freckled." Attention has been called 
to the occasional occurrence of lentigo in the protected parts of the 
skin. Dr. White, of Boston, in an interesting paper on melano- 



CHLOASMA. 361 

derma, 1 calls attention to the fact that exposure to sea-air and fog, 
with obscuration of the suu, is sufficient to produce the result. 

Pathology. — Freckles are due to an increase of deposit of pigment 
in definite areas of the epidermis, never in the corium. Lesser urges, 
with strong probability in his favor, that there is always a congenital 
predisposition to these pigment formations which requires certain 
external conditions for development. 

Treatment. — The treatment of lentigines is that of chloasma and 
other pigmentations of the surface. Prof. Wertheim, of Vienna, 
advises : 

R. Hydrarg. ammon. muriat. gr. lvj ; 3 75 

Bismuth, magister. gr. lij ; 3 50 

Ungt. glycerini §j ; 32 M. 

Sig. To be applied only every other night. 

Bulkley employs : 

R . Hydrarg. chlor. corros. gr. yj ; 4 

Acid, acetic, dilut. f £ij ; 8 

Boracis £)ij ; 2 66 

Aq. ros. fgiv; 128' M. 

Sig. To be applied night and morning, at first with gentle brush- 
ing ; afterward by rubbing. 

Hardaway touches each freckle with a rather stiff needle connected 
with the negative pole of a galvanic battery, and finds the results 
satisfactory. 

Most of the secret methods employed by charlatans for the removal 
of freckles depend for their success upon thorough blistering of the 
surface. Inasmuch as by this process the epidermis is removed, it 
is evident that the pigment of its cells is also removed with it; and 
the new epidermis is for a time quite free from blemish. But in 
all such cases the ultimate result is a deeper and more persistent 
pigmentation than that which was previously visible. 

Chloasma. 

Gr. x^oa^a), to possess a greenish color. 

Chloasma is that condition in which occur yellowish to blackish, finger-nail 
to palm-sized, circumscribed, diffuse, and ill-defined maculations of the 
cutaneous surface, due to an excessive deposit of pigment. 

Symptoms. — In this affection the skin is either diffusely discolored 
in various shades, or the maculations occur in patches larger than 
those of lentigo, fairly well-defined, and irregular in contour, the so- 
called " liver-spots." In color they vary from a scarcely perceptible 
staining of the skin, which requires a strong light for its detection, 
to a deep yellow, a yellowish-green, a chocolate-brown, or a blackish 
shade (Melanoderma). They may be either idiopathic or symp- 
tomatic in character. 

1 Boston Med and Surg. Journ., May 16, 1878, p. 624. 



362 DISEASES OF THE SKIN. 

The idiopathic varieties of chloasma are produced by all externally 
operating agencies, in eonsequence of which an undue afflux of blood 
is persistently determined to any portion of the skin. It is largely 
from the blood that the pigment is derived, and hence the stains 
produced by the latter are, to a certain extent at least, proportioned 
to the hyperemia, stasis, or extravasation of the vascular fluid. 
Among these externally operating agencies may be named, pressure 
and friction (as over the part covered by the pad of a truss) ; trauma- 
tism (as after the severe scratching of the skin affected with lice, 
eczema, or scabies); heat (as in diffuse "tanning" of the face, or 
"sunburn" following exposure to the solar rays) ; and the toxic or 
irritating effect of externally applied substances, such as mustard, 
capsicum, cantharides, and other articles capable of producing either 
vesication or pustulation of the surface. The physician should 
always remember the possibility of producing long, persistent, or 
even permanent pigmentations of the skin upon the face, shoulders, 
and bosom of young women especially, by the repeated application of 
such topical medicaments. 

The symptomatic varieties of chloasma are the results of disorders 
either systemic or involving the internal organs. They occur as 
either circumscribed or diffuse, localized or generalized, spots, 
mottlings, stainings, or " masks " of the skin ; and vary in color from 
the lightest to the darkest shades. One of the most common, and 
at the same time the most marked of these, is Chloasma Uterinum, 
so called because of its frequent association with certain physiological 
or pathological conditions of the uterus, both among married and 
single women. Thus in pregnancy, sterility, hysteria, chlorosis, 
ovarian disorders, and tumors, and functional derangements of the 
uterus, there can be observed at times a facial discoloration extending 
equably over the forehead and reaching nearly to the line of the hairs 
at the scalp, in the form of a faint or decidedly yellowish, reddish- 
yellow, or deep brownish tinge. At other times, the discoloration is 
macular and asymmetrical, involving the lids, the cheeks, the lips, or 
the chin. When the chloasma assumes the mask-like form, it is 
usually most pronounced over the forehead, but may involve the 
whole facial region, being less distinctly defined below than above. 
Similarly, the well-known changes occur in the areola of the nipple, 
along the linea alba, and about the external genitalia. 

Melanoderma, or Chloasma, Cachecticorum 

is another of the symptomatic pigment -disorders, characterized by 
the changes in the color of the integument of the subjects of tubercu- 
losis, . syphilis, cancer, chronic alcoholism, malaria {e.g., " Chagres 
fever"), and other disorders. 

The peculiar bronzing of the skin in Addison's Disease, formerly 
thought to be due exclusively to lesion of the supra-renal capsules, 
is of the same nature. Overbeck and Greenhow have shown that 
the capsules may be completely destroyed without changes in the 



CHLOASMA. 863 

skin-color resulting. The pigmentation may be general or partial ; 
and in the latter case is without definite lines of demarcation. It is 
commonly most pronounced over the face, neck, scrotum, groius, 
axillae, and nipple and areola The hairs become coarse and dark ; 
and dark patches are at times visible over the mucous surface of the 
lips, gums, and other parts of the mouth. The bronze or mulatto- 
like color of the skin is intensified by stimulation or erosiou of the 
cutaneous surface. In these cases there is generally marked asthenia, 
with a feeble pulse, with anorexia and other signs of gastro-intestinal 
disorder. When the result is fatal, there may or may not be recog- 
nized pathological alterations of the supra-renal capsules. 

Among the cutaneous disorders capable of producing skin pigmen- 
tation may be named scleroderma, lepra, angioma pigmentosum et 
atrophicum, eczema, especially e. venis varicosis; and general exfolia- 
tive dermatitis. 

From all of the discolorations named above, which are due solely 
to deposition in excess of coloring matters normally existing in the 
skin, it is necessary to distinguish the various dyschromia? which are 
owing to the introduction into the integument of coloring substances, 
either supplied by other portions of the body or entirely foreign to it. 
Thus, in icterus, the bile may color the skin from a light yellow to a 
dark chrome color, the duration and severity of the cutaneous symp- 
toms depending upon the nature and gravity of the hepatic disease. 
It is frequently accompanied by pruritus in various grades of severity, 
the exact causes of which are obscure. 

In Argyria, the bluish, bluish-gray, slate-colored, or bronzed 
coloration of the skin results from the introduction from without of 
the nitrate of silver. It is most commonly the result of the adminis- 
tration of the drug in the treatment of epilepsy, but is said also to 
have resulted from the topical application of the silver crayons to the 
throat, to the conjunctiva?, and even to the skin. Under what form 
the silver produces this effect, whether as an albuminate or other 
salt, is not known. The deposition, however, occurs in the form of 
minute particles of the metal in the connective tissue of the derma. 
The discolorations are most evident upon the parts of the skin ex- 
posed to the light, as the face and hands ; but the author has seen the 
chest and lower extremities similarly stained. The connective tissue 
of the viscera is also at times involved, showing thus that the action 
of light is not essential to the production of the dyschromia. Two 
cases are reported as relieved by the administration of the iodide of 
potassium. 

The administration of arsenic in full doses for relief of nervous 
disorders in children has been followed by a characteristic dull 
brownish or dirty-colored discoloration of the skin of the neck and 
chest. Several cases of this sort have been presented to the author's 
observation in his clinic by Dr. H. JST. Moyer. 

By the process of tattooing, lastly, several mineral and vegetable 
substances are directly introduced into the corium by means of 



364 DISEASES OF THE SKIN. 

needles, for the production in the skin of various devices in colors. 
Individuals whose entire integument has been thus artificially covered 
with figures of different patterns by tattooing with indigo, vermilion, 
and cinnabar have been from time to time exhibited in this country. 
The results are indelible. Post-mortem, these pigments have been 
discovered not only in the derma, but in the lymphatic ganglia 
nearest the site of their introduction. 

Pathology. — The lentigines, ephelides, and chloasmata are all due 
to excessive deposit of the natural pigment of the body in the rete 
mucosum of the epidermis. Restoration of the normal color of the 
skiu is usually proportioned to the extent and depth of the deposit, 
but the process is always very gradual. It can lie well studied in the 
slow bleaching of the pigmentation of syphilitic cicatrices upon the 
lower extremities. In the dyschromias due to the introduction of 
coloring- matters foreign to the body or foreign to the skin, the corium 
and subcutaneous connective tissue are commonly stained. 

Diagnosis. — The diagnosis of the cutaneous pigment hypertrophies 
is readily effected by observing the persistence of the discoloration 
under pressure ; the absence of all symptoms of hyperemia, inflam- 
mation, and secondary changes in the skin, as also by the charac- 
teristic shades of color presented to the eye. In tinea versicolor 
there is usually slight furfuraceous desquamation, and the existence 
of a vegetable parasite is readily demonstrated by the mieroscope. 
The rare pigmentary syphilide is usually seen upon the neck and 
shoulders of infected women in the form of yellowish to brownish 
maculations, often arranged in an irregular network. It is, indeed, 
one of the symptomatic chloasmata. 

Treatment. — In all the symptomatic pigment anomalies, the indi- 
cations for treatment are presented by the disease which begets the 
cutaneous disorder. 

The local treatment of both the idiopathic and symptomatic 
varieties of the disease demands the use of external applications 
which will hasten the physiological reproduction of the epidermis, 
substituting thus new and unpigmented for old and pigmented epi- 
thelia. This must also be accomplished without the artificial pro- 
duction of such an hyperemia as will tend to add to the very 
coloration which it is attempted to relieve. The substances used for 
the slow accomplishment of this end are muriatic and acetic acids, 
borax, sulphur, tincture of iodine, potash, and soda (including the 
soaps of these alkalies), and the mercurials. None of these is more 
generally employed than corrosive sublimate, which constitutes the 
basis of most of the cosmetic lotions sold in the shops. 

The following are formulae given by Dr. White 1 for use in the 
evening. The preparation in each case should be left upon the sur- 
face during the night, and removed by a soap and water washing in 
the morning. They are to be used for weeks in succession, but only 
after a cautious preliminary testing of the sensitiveness of the skin 



CHLOASMA, 



365 



to their action. In order to avoid the possibility of error, the prac- 
titioner would do well to order a poison-label upon all vials con- 
taining the sublimate : 



R. 



Hydrarg. am. chlor. 
Bismuth, magister. 
Amyli ) 
Glycerin, j 

Ammon. muriat. 
Aq. colognien. 
Aq. 

Hydrarg. bichlorid. 

Acid. mur. dil. 

Glycerin. 

Alcoholis I 

Aq. ros. J 

Aq. 



aa 5ij ; 

aa .|ss ; 

3ss; 

fsj; 

Oss'; 
gr. vj ; 

aa f 3ij ; 



16 

2 

32 

256 

4 

128 1 



M. 



M. 



The following are formulae for ointments given by Kaposi : 

16 



R. Hydrarg. ammon. 
Sodse biborat. 
01. rosmarin. 
Unguent, simpl. 



R . Acid, boracis } . 
Cera? alb. } 

Paraffin. 
01. amygd. dulc. 

Van Harlingen recommends : 

R. Hydrarg. chlor. corros. 
Zinci sulphatis j 
Plumbi subacetat. j 
Aq. dest. 



aa ^ss ; 


gtts. x ; 

5j; 


aa 3} ; 


3ij; 

5J; 


gr. vss; 


aa, 3ss ; 



fgiv 



128 



M. 



Sig. Lotion, for external use, morning and evening. 



The rapid removal of pigmented patches is accomplished, in 
Vienna, by covering the part with strips of linen dipped in an 
aqueous or alcoholic solution of corrosive sublimate of the strength 
of four grains (0.26) to the ounce (32.), with which also the dressing 
is occasionally moistened. Vesiculation is usually accomplished in 
about four hours, when the serum is evacuated by puncture, and the 
detached epidermis covered with any inert dusting powder. The 
resulting crust falls in about eight days. The procedure is attended 
with the danger of producing, in the end, the precise deformity which 
it seeks to remedy, a danger explained above. 

The internal administration of the iodide of potassium, recom- 
mended for the removal of argyria, has in my hands failed of any 
good results. Yandell's two patients, one completely and the other 
partially relieved, were both syphilitic. One of my patients was a 
veteran syphilitic, fifty years of age. 



366 DISEASES OF THE SKIN. 



2. Of Epidermal and Papillary Layers. 
Keratosis. 

• ■!'. fiipag, a horn. 

The term Keratosis was first applied by Lebert to hypertrophic 
lesions of the epidermis. It has since been made to include changes 
in both the epidermis and curium ; and is employed by some authors 
in a generic sense to embrace a number of both localized and general 
hypertrophic-, including callosities and corns. In the classification 
of the American Dermatological Association, however, it includes 
merely the two disorders described below, the others embraced by 
authors in the same category being in these pages separately con- 
sidered. 

[A.] Keratosis Pilaris. 

Keratosis Pilaris is a disorder, chiefly of the extremities, characterized by 
multiple, millet-seed sized, whitish, grayish, or slightly reddish aggregations 
of epithelium, about the orifices of the hair-follicles. 

Symptoms. — This condition, termed also Lichen Pilaris, and 
Pityriasis Pilaris, may be a mere temporary and functional dis- 
turbance of the skin, awakening no subjective sensation, inappreciable 
by the patient, and apparent only to the careful observer, or it may 
really constitute a disease. Its symptoms are the occurrence of pin- 
head sized, pointed elevations of the surface, which may be described as 
papules, though, strictly speaking, they are not such, constituted by 
an accumulation of horny epithelia and a small quantity of inspissated 
sebum about the lanugo hairs of the extensor surfaces of the extremi- 
ties and trunk. These aggregations of material are usually of a dirty 
whitish or grayish hue, and pierced by a lanugo hair implauted in 
the follicle about which the abnormal condition exists. Occasionally, 
however, the hairs are of the finer and shorter kind, and are often 
coiled in or otherwise covered by the little heaps of epithelial debris. 
The skin of the individual thus affected is generally harsh, squamous, 
and dry to the touch ; being also, in the majority of cases, long 
unwashed. The color of the quasi-papules also differs with the 
complexion of the individual ; at times they have a distinctly reddish 
tinge. They are often surmounted by a scale. 

The condition is sufficiently common in skins long uncleaused by 
ablution, and can thus be artificially produced. In some individuals 
it persists for long periods of time, and awakens no concern. In 
others, and especially in children, it speedily becomes the source of a 
pruritus, and each lichenoid papule may be then transformed into an 
urticarial wheal, with distinct and sometimes very annoying, pricking 
and tingling sensations, the entire trouble being at once relieved by 
a bath in warm water with soap. In other cases, especially in adults, 
an exaggerated form of the disease can be recognized, the skin pre- 
senting a roughness to the touch suggestive of the nutmeg-grater, 



KERATOSIS. 367 

and exhibiting numerous fine, conical, grayish, horn-tipped filaments, 
which several dermatologists are disposed to regard as a form of 
ichthyosis. Here, there is doubtless a true hypertrophy of the 
epidermis. In the former case, there is scarcely more than a 
mechanical accumulation of effete organic material. There can be 
little doubt that the malady, simple though it be in character at 
the onset, may become the first stage of a series of chronic cutaneous 
disorders. Tilbury Fox has reported four cases in which the disease 
was well marked, under the title Cacotrophia Follictjlorum, the 
name being employed to designate its peculiarities as to wide distri- 
bution over the body, implication of the deeper portion of the follicles, 
and its congenital history. In these cases, the reddish tint of the 
lesions is distinctly shown. 

Pathology. — The disease is produced by the accumulation of the 
cells of the horny layer of the epidermis and sebaceous material 
about the orifices of the hair-follicles. In some cases the result is an 
irritation which produces a more or less persistent hypersemia of the 
periglandular tissue. 

Etiology. — Puberty and uncleanliness have been assigned as a 
cause of the disorder ; and both conditions may be in some patients 
effective. A careful study of a group of exaggerated cases, however, 
occurring in adult men and women, suggests more essential reasons 
for the disease. In such exaggerated cases, the outer faces of the 
limbs and even the entire face of the belly may be Covered with 
faintly pinkish or bright reddish firm papules, many of them scale- 
capped, all seated at the orifice of a hair-follicle. In these patients 
there may be a history of regular ablution and persistence of the 
malady long after puberty. But in general they will be seen to have 
peculiarly thick, coarse, usually dark colored skins, and also to be 
persons of marked muscular vigor and unusual development of most 
of the other bodily tissues. In brief, the disorder seems to be due 
often to marked inherited predisposition in persons of vigorous 
constitution. The varieties of keratosis pilaris seen in cachectic 
hospital patients, and in persons who have aggravated the disease by 
inducing a medicamentous rash upon the person, belong to a different 
category. Patients in the two last-named classes may be so perfectly 
relieved that there is no predisposition to return of the disorder, a 
relief not always to be secured by the others. 

Diagnosis. — The disease should be readily recognized by the 
peculiarities of its seat, its course, and the nature of its symptoms. 
From ichthyosis, it can be distinguished by its limitation to the 
orifice of the hair-follicle ; from the transitory condition known as 
"goose flesh," by its persistence after the surface of the skin is 
thoroughly warmed ; from papular eczema and the other lichenoid 
eruptions, by the relatively insignificant character of the lesions and 
their evident association with follicular inertia. 

It is a matter of very considerable importance to distinguish this 
disease from the papular syphilodermata, since many male patients 
have for years swallowed medicaments for relief of a supposed 



368 DISEASES OF THE SKIN. 

syphilis whose sole symptom is a keratosis pilaris. But the papular 
syphilodermata arc not persistent year after year, not persistently 
symmetrical, and not limited largely to the outer faces of the limbs, 
especially of the thighs. They are preceded by a history of infection 
and invariably accompanied by some other manifestations of the dis- 
ease. They are not limited to the orifices of the hair-follicles, and 
are not capped by the peculiar horny scaling tip of the papule of 
keratosis pilaris. 

Treatment. — For patients affected with this disorder in its typical 
forms it is not sufficient merely to order a bath. The bathing should 
be conducted systematically for years at a time. 

As soon as it can be well tolerated, the patient should be urged to 
bathe the entire surface of the body every morning, by the use of 
the sponge and cold water, following this with brisk friction by the 
aid of a coarse towel or flesh-brush. The daily and habitual use of 
this cold bath continued for years, iu persons who can tolerate it 
(and patients affected with keratosis pilaris are usually of this class), 
accomplishes results of the most satisfactory character, exerting as it 
docs, a profound influence on the nutrition and healthfulness of the 
skin. 

For immediate treatment, however, of the most of these cases the 
hot bath with the soap is desirable. This may be repeated as often 
as required to remove the lesions, and followed, in the more urgent 
cases, by inunction with the fats or oils. In the congenital and 
severer cases, such as those described by Fox, cod-liver oil, internally, 
should be ordered. 

[B.] Keratosis Senilis. 

The senile changes in the skin are commonly of the character 
studied by Neumann, in which granular opacities appear in rows in 
the corium, giving it a dull greenish-yellow or saffron-colored hue. 
Later, the fibrillse of the corium are almost entirely replaced by 
finely granular masses, the remaining fibres becoming swollen and 
gelatiuiform, reverting thus to an embryonic type. 

Side by side with these degenerative changes, but also without the 
latter, the skin of the aged may become harsh, dry, and unusually 
cornified either diffusely or in certain definite regions, such as the 
hands, feet, or extremities. This may be regarded as the simplest 
form of keratosis senilis. The skin of the entire body, or of the 
region affected, is then dark in color, dry to the touch, occasionally 
covered with fine, rather adherent scales representing merely attached 
and cornified cells of the horny layer of the epidermis, and notably 
unprovided with the natural unguent of the skin. 

In a more advanced grade of this affection, the skin undergoes 
changes which are closely allied to epithelioma, and which indeed 
often both furnish the first symptoms of that affection and also 
coexist with its gravest destructive effects. The skin, in these cases, 
more commonly of the face, hands, or forearms, less often of the 
feet, legs, and genital regions of the aged, is covered with thin, horny, 



MOLLUSCUM EPITHELIALE. 369 

often greasy looking, pin-head to nail-sized and larger, dark yellowish 
plates or scales, between which the integument which has undergone 
the atrophic changes in the senile skin, is visible. Pigmented puncta 
and macula? may also appear, scattered irregularly over the surface, 
with rough, dirty yellowish to dark brownish, granular accumula- 
tions upon the skin of certain regions, such as the clefts beside the 
alse of the nose, the temples, etc. The appearance is quite suggestive, 
in some cases, of a seborrhoea sicca of the face. In many of the 
patients exhibiting these features a fully developed papillomatous, 
superficial, or deep epithelioma may be present. In other cases one 
or more varieties of the senile wart may be visible, as described in 
the chapter on verruca. 

Viewing the subject of senile keratosis in the light of the knowledge 
had upon the subject to-day, it must be admitted that the boundary 
lines between it and epithelioma are not well established. Unques- 
tionably the exaggerated lesions of the former disease are frequently 
the first stages of the latter, and the treatment of the skin of the 
aged, conducted on the general principles already set forth, should 
never lose sight of the possibly serious consequences in one or more 
regions of the skin affected. 

Molluscum Epitheliale. 

Lat. molluscus, soft. 
Epithelial Mollusca are smooth, globoid or acuminate bodies, situated either 
within or upon the skin, and in the latter case either sessile or peduncu- 
lated, varying in color from a yellowish- white to a dark pink, and in size 
from that of a piri-head to that of a bean. 

Symptoms. — Molluscum Epitheliale, a disease first, recognized by 
•Bateman, in 1817, under the title Molluscum Contagiosum, is to 
be distinguished from auother, known for a long time as molluscum 
fibrosum. The two disorders are quite distinct, and no longer to be 
confounded by a similarity in their names. 

Typical mollusca are firm, roundish bodies, averaging in size the 
dimensions of a pea, and in color varying from a waxy whitish hue, 
nearly that of the integument, to the dark red tint of all injected 
masses. They are either imbedded in the skin, or project from it in 
semi-globular tubercles, sessile or pedunculated. Usually a dark- 
colored aperture can be detected at the apex or side of the lesion 
from which, on pressure, milky and curd-like, semi-fluid contents 
can be made to exude. Occasionally inspissated, or even horn-like 
masses project from these orifices, as though forced out by a vis a 
tergo. The disease is rare, and the lesions usually single and isolated, 
though hundreds may appear upon the person of one individual. 
They consist of semi-fluid collections derived from that portion of the 
rete which either lines the sebaceous glands or penetrates between the 
papilla? of the derma ; or are actual transformations of the glands into 
cornified amorphous deposits, surrounded by thickened parietes. They 
may be artificially removed ; or be shed spontaneously ; or inflame, 



870 



DISEASES OF THE SKIX 



suppurate, and result in circumscribed abscesses; or terminate by 
ulceration. Most often they are insidious and slow of development; 
and may persist for years without producing annoyance or subjective 
sensation. They occur on the face, the side of the neck, and the 
nucha; on the penis and scrotum of meu, and the breast and labia 
of women; on the trunk ; on the flexor surfaces of the extremities, 
and the dorsal surfaces of the hands and feet. They are most com- 
mon in children. In consequence of the depression of the centre of 
the little tumors (which Hutchinson has aptly likened to small pearl 
buttons), they may suggest the lesions of variola, and are hence 
described by French writers under the term, Varioliform Acxe. 

Fig. 40. 




Molluscum Epitlieliale. (After Allex.) 



Hebra, Virchow, and Nicolaysen have reported colossal mollusca, 
as large as an orauge or a small cocoauut. Microscopical examina- 
tion of these gigantic lesions demonstrated their identity with the 
smaller tumors. Similar smaller bodies have been found interspersed 
among epitheliomata. 

Etiology. — In England, where the disease was first recognized and 
where, according to Hutchinson, it is far more frequent than on the 
continent of Europe, the belief in its contagiousness is quite generally 
accepted. Excellent authorities are, however, divided upon this 
question. At present, therefore, it can only be definitely stated that 



MOLLUSCUM EPITHELIALE. 371 

the contagiousness of molluscum is not yet established. If contagious, 
the lesions certainly possess this power of transmission in a feeble and 
imperfect degree, one much inferior certainly to other lesions recog- 
nized as contagious. Retzius, Vidal, Peterson, and Wigglesworth 
succeeded in producing the disease by inoculation of the contents of 
molluscous tumors. Allen, in an interesting communication upon 
the subject, 1 reports an abortive result from an inoculation practised 
in two places upon himself by Dr. Bulkley. He reports fifty cases 
observed among children in an infant asylum of New York City, 
and expresses himself strongly in favor of the contagious character 
of the disease. Experiments with inoculation have been, however, 
often unsuccessful. The proofs of contagion rest chiefly upon the 
circumstance of lesions observed simultaneously or successively on 
the breast of a mother and the mouth of her nursling, as observed 
by both Bateman and Allen, or upon the successive development of 
mollusca in several members of one family. These are possibly 
explicable as coincidences. Fox, of New York, has called attention 
to an interesting relation which would seem to subsis tbetween mol- 
lusca and verruca, or ordinary warts. If simple warts are ever 
shown to be in a feeble degree contagious, it can scarcely be doubted 
that a demonstration of the contagiousness of mollusca will soon 
follow. According to Kaposi, eczema, sweating, pruritus, and macera- 
tion of the skin, predispose to their occurrence. 

There are not sufficient grounds for assuming that, in adults, they ' 
are always associated with venereal disease. They are not rarely 
seen in large numbers upon the scrotum of youths who have never 
exercised the sexual function. 

Pathology. — Upon section, a typical molluscous tumor is found to 
contain either a thick caseous fluid, or a mass of smooth, whitish, and 
roundish bodies, which are often clustered about a short stalk. Micro- 
scopically, these are seen to be composed 
of epidermal masses, fat globules, and FlG - 41. 

peculiar bodies of oval shape, partly or 
wholly contained in an epithelial pod, 
the so-called "molluscous corpuscles." 

The origin and significance of these 
corpuscles have been the subject of a 
great deal of careful investigation with 
no little divergence of opinion as to the 
result. The disease has been consequently 
regarded by many authors as one con- 

o , J J Molluscous corpuscles. 

cernmg the sebaceous glands, and the (After Kaposi.) 

fluid or more or less solid contents of the 

tumors as the result of the various metamorphoses which the pent-up 
secretion of those glands underwent. By such authors, the disease is 
termed " molluscum sebaceum," " contagiosum," etc., and is classified 
with the sebaceous gland disorders. 

1 Journ. of Cutan. and Yen. Bis., August, 1S86. 




372 DISEASES OF THE SKIN. 

But the later studies of Retzius, 1 Lukomsky, 2 Renaut, 3 Yidal, 4 
and Thin 5 make it clear thai the disease is one which concerns chiefly 
the rete mucosura of the epidermis. The name molluscum epi- 
theliale, first suggested in this connection by Virchow, in the title 
epithelioma molluscum, is hence seen to be appropriate in the desig- 
nation of the disease. 

Molluscous tumors may evidently take origin either in the portion 
of the mucous layer whose involution forms the lining membrane of 
the sebaceous gland, or in the prolongations of the rete downward 
between the papillne of the corium where there is no follicle. In 
either situation, the molluscous elements are earliest recognized as 
simply enlarged epithelia which assume, as a consequence of this 
enlargement, a globular form. In the midst of these, there are 
certain individual elements which acquire a granular appearance, the 
granular masses finally giving place by union to a globoid or oval- 
shaped body, large, shining, and stratified or homogeneous. This is 
the molluscous corpuscle which represents a colloid metamorphosis 
of the original epithelia. According to Ranvier, the stratum granu- 
losum of the epidermis is composed of elements which contain 
minute particles of a substance called eleidiue, the keratogenic 
material by whose transformation the stratum corneum is actually 
produced. This substance Renaut declares to be abundantly de- 
posited in the enlarging corneous globes characteristic of molluscum; 
and the process is by him shown to be identical with that occurring 
in the transformation of the elements of the mucous into those of 
the horny layer of the skin. The pathological resemblance of cer- 
tain molluscous bodies to epithelioma is thus very clearly suggested. 

According to Thin, 6 the internal root-sheath of the lanugo follicle 
is the original source of the disease, whence molluscous elements 
pass to inoculate, at various points about the follicular orifice, the 
adjacent epidermis. The coalescence of these points forms the tumor, 
in the course of the development of which the lanugo hair is shed, 
and the sebaceous' gland disappears. 

Auspitz denies that the transformation of the prickle-cells of the 
epidermis into molluscous bodies has anything in common with col- 
loid or amyloid degeneration. Robinson classes the disease with the 
new growths. At present, we must be content with recognizing the 
molluscous corpuscle as the result of a transformation undergone by 
the prickle-cell. 

Diagnosis. — Mollusca resemble the lesions of variola more than 
any other cutaneous phenomena. They are, however, readily dis- 
tinguished from the latter by their chronicity, their semi-fluid con- 
tents, the absence of febrile symptoms, and the career of the vario- 
lous pustules. From warts they are also differentiated by their 
contents, hemispherical shape, and the dark punctum almost invari- 
ably present ou one part or another of the lesion. 

i Viertel f. Derm, and Svph., iv. Hit. 3, 1877. - Virchow'a Archiv, Bd. lxv. 

3 Lyon Med., July 25, 1880 4 Sue. de I5iol..j,'k\ 1877-1878. 

l> Jouni. of Aiiiit. und Puys., vol. xvi., 1881; and Brit. Sled. Journ., Jau. 15, 1881. 
6 Loc. Cit 



MOLLUSCUM EPITHELIALE, 



373 



Molluscum epitheliale in no way suggests molluscum fibrosum, 
with which it has only been confounded in consequence of the simi- 
larity in the two names. The tumors of molluscum fibrosum are 



Fig. 




The author's rare form of molluscum verrucosum. (From a painting in oil.) 

solid new growths, usually occurring in great numbers upon the 
trunk of individuals in adult years. They may attain enormous 
dimensions of several pounds weight, and though in cases they de- 



374 DISEASES OF THE SKIN. 

generate by ulceration, they never have the curdy contents of mol- 
luscum sebaceum. 

Papillary warts are to be distinguished from mollusca, though 
without question lesions are to be occasionally seen of a type inter- 
mediate between the two forms. Warts are to be recognized by their 
general papilliform character, and their evident relation to the papil- 
lary layer of the corium overlaid by a thickened stratum corneum. 

Physicians are occasionally consulted by patients who have dis- 
covered mollusca upon the genitals, and who suppose these lesions to 
be of venereal origin. An error in this respect can scarcely be 
committed by the expert. Neither the solid papule of the initial 
lesion of syphilis when observed on the skin of the penis, nor the 
pustule and resulting ulcer of the chancroid are ever characterized 
by the particularly waxy look of genital mollusca with their de- 
pressed puncta. In such cases, the inguinal glands should always 
be carefully examined, remembering, however, that a forcibly 
squeezed and cauterized molluscum may be accompanied by a sympa- 
thetic adenopathy. 

Treatment. — Molluscous tumors may be removed by ligature, 
scissors, knife, curette, or the needle in contact with the negative pole 
of a galvanic battery, their contents having been previously expressed. 
When desired, the surface may be first chilled or frozen with the 
ether spray, to diminish the pain of the trifling operation. Bleeding 
is easily arrested by a pledget of lint. Occasionally the point of a 
crayon of nitrate of silver may be introduced, after their removal, 
either to check hemorrhage or to insure destruction of the cyst. 
According to Hebra, the return of the complaint, when it occurs at 
all, may be expected at points where no tumors have been removed. 

When the lesions are small and numerous, they may be made to 
exfoliate by the local application of green soap. Removal of the 
larger lesions may be followed by minute cieatrices. 

Prognosis. — The disease can always be terminated by removal of 
the tumors — the process to be repeated in case of recurrence. Cica- 
trices, when these result, are of trifling moment. 

Callositas. 

Lat. callus, hard flesh. 

A callosity is a whitish-gray, yellowish-gray, or brownish, semi-transparent, 
localized and circumscribed thickening of the epidermis of the skin, due to 
hypertrophy of its horny layer, most commonly occurring upon the hands 
and feet. 

This condition is also termed Tylosis, and the callosity itself, 
Tyloma. Callosities are superficial, circumscribed, dirty white, yel- 
lowish-white or darker, flattened, thickened, and horny patches of epi- 
dermis, dense in structure and usually insensitive. A section of the 
plaque shows it to be largest at the centre and least at the periphery. 
They vary in size from a finger-nail to a section of a hen's egg, being at 



CALLOSITAS. 375 

times larger ; and occur chiefly upon parts of the integument subjected 
to long-continued intermittent pressure, as the hands and feet ; also 
upon parts stretched over osseous prominences, as those over the 
ischia. They may be complicated by hyperemia, fissure, acute 
inflammation, or erysipelas ; and readily serve as foci of cutaneous 
disease (eczema, psoriasis, etc.). They are commonly encountered 
among mechanics, carpenters, shoemakers, etc. ; among persons wear- 
ing ill-fitting shoes (heel, ball, or big toes), stockings, or surgical 
apparatus ; among workers in metals, acids, or heated substances ; 
and among musicians (harpers, banjo-players, etc.). They are pro- 
duced by such external causes as pressure, friction, chemical agents, 
and heat. By careful consideration, they can be readily distinguished 
from eczematous, psoriasic, and ichthyotic patches, being always 
limited to the sites of external contact. 

They are said to be so characteristic of the several professions and 
trades, that by their locality alone they point in many cases to the 
occupation of the individual who exhibits them. Often they are, in 
these cases, essential to the prosecution of such work ; and their 
removal would only expose a tender epidermis to the operation of 
an injurious pressure or friction. 

They are, pathologically, pure hypertrophies of the stratum corneum 
of the epidermis, the deeper layers of the latter as also the coriuni 
and subcutaneous tissue being quite unaffected. 

Callosities require treatment only when they are sources of pain 
or discomfort. They may be removed ; surgically, by the knife ; 
chemically, by the destructive action of acids or alkalies ; rationally, 
by disuse of the part to an extent sufficient to interfere with the 
operation of the cause. When painful, they may be poulticed. A 
nightly soaking of the part with warni oil, kept in contact with the 
thickened epidermis during the hours of sleep, by a compress of 
flannel saturated with the same substance, will in the end always 
soften the induration. 

Callositas of the Hands, with Unusual Complication 
[reported by Dr. Morrison, 1 of Baltimore], is illustrated by the case 
of a negro who was engaged in stoking the fires of a steamer. In 
this instance the combined effects of heat and friction resulted in 
ulcerations beneath the callosities which eventually produced necrosis 
and fall of some of the phalanges. This patient recovered as soon 
as the hands were properly protected, a fact which seems to justify 
the assignment of this and similar cases to a class apart from those 
which follow. 

Perforating Ulcer of the Foot [Malum Perforans Pedi; 
Mai Perforant du Pied]. This disorder, first named by Vesigne, has 
been studied by Messrs. Savory and Butlin, 2 Mr. Treves, 3 I) u play, 4 
Michaud, 5 and others. 

i Journ. of Cutan. and Vener. Dis., Jan. 1886. 2 Med. Chir. Trans., vol. lx., 1879. 

3 Lancet, Nov. 29, 1884. * Arch. gen. de Med., 1876. 

5 Lyon Med., 1876. 



376 DISEASES OF THE SKIN. 

The name is an unfortunate one, since many cases to be classed 
only in this category, have neither ulcerative nor perforating symp- 
toms. 

The first symptom is a proliferative thickening of the epidermis, 
like a corn, usually single, occasionally multiple, appearing over a 
point of pressure (first or fifth metatarso-phalangeal joint, etc.). 
Inflammation aud suppuration proceed beneath this thickening, 
spreading first to the soft parts of the sole and then to the bone 
itself. Gradually a sinus forms, reaching from the side of the corn 
to the deeper parts involved. Meantime the skin in the neighbor- 
hood becomes greatly thickened, heaping itself especially about the 
sinus. The ulcer which eventually forms is roundish, deep, aud at 
times very destructive in its effects. 

Thus far, the lesion might be supposed to be the result merely of 
a greatly irritated corn, but other phenomena exhibited in these 
cases are quite inexplicable in this way. The nails are altered ; 
superfluous hair grows on the dorsal surface of the foot and the skin 
of the involved extremity ; pigmentation, erythema, or eczema may 
occur ; and the parts become affected with either anidrosis or hyperi- 
drosis. These disorders have, again, been noted as the result of 
spinal injury, congelation, posterior spinal sclerosis, ana?sthetic 
leprosy, and, in animals, after section of the sciatic nerve. Among 
the most common symptoms in typical cases are anaesthesia, neuralgic 
and rheumatic pains, hyperidrosis, and coldness of the feet. 

The author has had the opportunity of studying this disorder in a 
group of cases which illustrate both extremes of its symptoms. The 
perforating ulcer occurred in the following case : 

In the centre of a dense callosity which had formed over the right 
first metatarso-phalangeal articulation of a young man, there was 
exposed the orifice of a sinus which could not be made to close. 
The course of the disease was exceedingly iudolent, the parts being 
the seat of little pain. The weeping from the sinus was scanty, and 
it was not surrounded by granulations. It was more an annoyance 
at first, than a serious disease. Finally, by the aid of a fine probe, 
it was discovered that the sinus beneath led to exposed bone. A 
deep incision was made at this point, and the osseous surface 
thoroughly scraped, after which antiseptic dressings were applied. 
The sinus, however, reformed in time ; and it became finally neces- 
sary to amputate the toe and remove by the gouge a large portion of 
the head of the corresponding metatarsal bone. This operation 
proved successful in relieving the patient. 

The case next described represents a group in which typical symp- 
toms of the disease were marked without a tendency to ulceration. 
A servant maid, twenty-two years old, kept under observation in 
hospital for more than a year, had for several years previously, as 
also while under treatment, suffered from symmetrical recurrent 
tylosis of the soles of the two feet only, the hands being spared. A 
dense, thick, yellowish-gray cast of the entire sole of each foot was 
regularly shed every four months, leaving behind a soft, tender, and 



CALLOSITAS. 377 

irregularly mammillated epidermis. Persistent maceration of the feet 
for weeks at a time, poulticing, absolute disuse of the organs for 
months, mopping with from ten to thirty per cent, solution of caustic 
potash, applications of Hebra's diachylon salve, mercurial and tar 
ointments, were all futile in preventing the recurrence of the tylosis. 
After the cast of each foot was formed, the use of the organs was 
almost interdicted in the act of walking, on account of the pain 
which was induced. 

The nail of each toe of both feet was roughened, scabrous, friable, 
and tilted up from the matrix so as to approach the vertical position. 
The hands were the seat of a persistent hyperidrosis, being constantly 
clammy and macerated with the sweat that poured from them. The 
pulse was slow, ranging from fifty to sixty beats a minute. All other 
functions of the body were properly performed. 

In the group of cases to which reference is made above, there 
was always a symmetrical involvement of the entire sole or palm, 
either of both feet, or both hands and feet. The patients were young 
adults. The palms when involved never exhibited the translucent, 
yellowish, wash-leather-like appearance of the same condition of 
the soles, but rather suggested the dry, scaly features of the palms in 
certain forms of erythematous eczema of these parts, but always 
without itching, and always with coincident plantar tylosis. The 
soles, however, always presented the typical appearances of callositas 
throughout the entire region, the callosity reaching somewhat upward 
over the heel, and in some cases relatively sparing the instep. In 
some cases the nails were not involved. The feet were always as cold 
to the touch as in pernio. 

Pathology. — The disease is, without question, a trophoneurosis. 
Histological examination has shown destruction of the myelin and 
axis cylinder of twigs of nerves supplying the affected parts. Ac- 
cordiug to Messrs. Savory and Butlin, the sensory and nutrient fibrils 
of the involved nerves degenerate in consequence of pressure exer- 
cised upon them by increase of the endoneurium, the motor fibrils 
escaping, owing to their large size and thicker medullary sheath, a 
view plainly untenable for all cases. 

Diagnosis. — The diagnosis is between tuberculosis and simple cal- 
lositas, a distinction readily established by the evident neurotic phe- 
nomena seen in the so-called perforating disease of the foot. 

Treatment — Apart from the surgical interference called for by one 
class of cases, a roborant treatment, including the internal adminis- 
tration of iron and arsenic, has been followed by most favorable 
results. 

The Prognosis is doubtful. 



373 DISEASES OF THE SKIN. 

Clavus. 

Lat. clavus, a nail. 

Clavus, or Corn, is a circumscribed callosity usually found upon the toes, 
due to epidermal hypertrophy, and provided with a conical spur of horny 
tissue beneath, which is projected into a corresponding depression in the 
corium. 

Corns are hypertrophies of the horny layer of the epidermis, with 
the peculiarity of presenting inferiority a coniform prolongation, 
which, being pressed from without inward upon the sensitive papillae 
of the corium, excites pain in various degrees. They vary in size 
from peas to large chestnuts, and are dense and callous when occurring 
upon those prominent parts of the foot where the boot, shoe, or 
gaiter, exercises its greatest pressure. When occurring upon the 
lateral face of a toe in apposition with another, the corn originates 
usually from pressure through the medium of the neighboring digits. 
It is then softer, from exposure to greater heat and moisture. Corns 
are often weather-sensitive, being unusually painful before, during, 
or after the occurrence of storms, and should therefore not be con- 
founded with gouty or rheumatic deposits below the skin. They 
are composed of superimposed, and often concentrically arranged, 
layers of epithelium, between which are occasionally found minute 
hemorrhagic extravasations. They are occasionally seen upon the 
palms of the hands. 

At the periphery of the corn the corium is unchanged, but at the 
point where its central cone is pressed into the deeper structures, the 
papillae are either atrophied or quite absent. 

Corns are rationally treated by disuse of the feet, or the adjust- 
ment of properly fitted coverings for the same. They usually fall 
spontaneously after an attack of paraplegia and in the case where the 
lower extremities are confined for a few weeks in surgical apparatus 
for relief of a fracture. They may be softened by prolonged macera- 
tion in water, poultices, or, best of all, oil, as in the treatment of 
callosities. Erasion and excision may be practised, if demanded by 
an exigency. Where the sufferer must necessarily continue the use 
of the foot, the simplest and best treatment is as follows : The part 
is thoroughly macerated for half an hour, with water as hot as can 
be tolerated. Then the projecting callous portion of the corn is 
gently removed by cutting or scraping, till, as nearly as may be, the 
surface is level with the plane of the adjacent skin. The part is 
then dried, and the entire surface, both of the seat of the corn and 
the adjacent integument, is completely covered with many narrow, 
short, and nicely adjusted strips of Maw's moleskin plaster. When 
the trifling operation and dressing are complete, the patient should 
bear firm pressure over the corn without flinching, and walk with 
perfect comfort. The plaster remains till it separates spontaneously, 
which is usually in the course of a few days. The corn is then macer- 



CORNU CUTANEUM. 379 

ated at night with an oil poultice, as described above, and the dressing 
afterward reapplied, usually the second time by the patient. Persist- 
ence in this course is followed by complete relief if the coverings of 
the feet be properly fitted. Caustics, employed by many, are usually 
unnecessary when there is no ulceration of the hard corn ; and are in 
this situation frequent sources of great distress. They are chiefly 
valuable in the treatment of the soft variety ; but should always be 
applied with a skilled hand. 

For this purpose, the crayon of nitrate of silver or acetic acid may 
be employed. The proprietary "corn salves" sold in the shops 
commonly contain the ointment of the nitrate of mercury, which 
also is a useful application to the soft variety of corn. The latter 
should be protected by the interposition of absorbent cotton or wool 
from contact with adjacent digits. 

As a rule, the ringed corn-plasters sold in the shops are inferior to 
the dressing with the moleskin plaster described above, which is made 
to cover the entire corn. Anderson recommends the emplastrum 
salicylici for a similar purpose. 



Cornu Cutaneum. 

Lat. cornu, a horn. 

Cornua, or cutaneous horns, are circumscribed hypertrophies of the epidermis, 

forming irregularly shaped, spur-like excrescences of different sizes. 

Cylindrical, conical, straight or twisted, angular and otherwise 
irregularly shaped and sized corneous eminences, single or multiple, 
are occasionally seen projecting from the scalp, forehead, nose, lips, 
ears, penis, and extremities. They are named from their resemblance 
to the similar appendages in horned cattle, but widely differ from the 
latter, which are always implanted upon osseous tissue. They are 
formed of dense and massed columns of epithelia, often resting upon 
somewhat prolonged papilla?. Occasionally, on section, they exhibit 
the concentric arrangement of the epithelia seen in corns, but, unlike 
the latter, have reentrant basal depressions into which the papillae 
below penetrate. At times they are implanted in a dilated follicle, 
in which case the glandular elements participate in their formation. 
At times, also, they represent a corneous transformation of the epi- 
thelia which constitute warts. They are seen in all colors, but are 
often between a yellowish-brown and a brownish-black, with a 
fissured or wrinkled or longitudinally grooved exterior, like rough 
bark. They may be painless, or, like the other keratoses, become 
the seat of inflammation in various grades. They may be short or 
several inches in length. The largest specimen ever under the 
author's observation was seen by him iu France, on the forehead of a 
man, where it had existed for fifteen years. It measured three 
inches in length. A few cases have been recorded in Chicago. They 
may be shed spontaneously, never to return or shortly to reappear. 
They occasionally develop into epitheliomata, as has occurred once 



380 



DISEASES OF THE SKIN. 



under the author's observation, in a gentleman over sixty years of 
age, whose epithelioma developed from a horn on the dorsum of the 
right hand, projecting about three-fourths of an inch. 



Fig. 44. 




Varieties of cutaneous horns. 



At the meeting of the American Association of Genito-Urinary 
Surgeons in 1887, Dr. Brinton, of Philadelphia, exhibited an ante- 
riorly curved horn one and seven-eighths of an inch long and three- 
eighths of an inch in circumference, removed by him from the glans 
penis of an elderly patient, no member present having then seen a 
similar growth in that locality. Only fourteen cases are on record 
of a similar growth in this situation. 

In a horn growing from the lower lip of an elderly man exhibited 
at the author's clinic in 1886, the growth was longitudinally fur- 
rowed, and also at somewhat regular intervals transversely furrowed, 
presenting then the appearance of the joints of the sugar-cane. 



VERRUCA. 381 

Pathologically, these hypertrophies are first developed either within 
a closed atheromatous cyst, or from remarkably elongated papillae 
of the corium. They are made up of cornified and hypertrophied 
epidermal cells. 

Horns may be removed by extirpation, after which the surface 
upon which they were implanted should be carefully and completely 
cauterized. 

Verruca. 

Lat. verruca, an excrescence. 
Verruca, or Warts, are pin-head to bean-sized and larger, soft or hard, cir- 
cumscribed elevations due to bypertropby of both the epidermis and papillae 
of the skin. 

Warts are cutaneous excrescences; sessile or pedunculated; pointed 
or flat ; smooth, rugous, or having a cauliflower appearance ; pig- 
mented in various shades, or of the natural color of the skin ; con- 
genital or developing after birth. They may be single or multiple, 
and occur upon the hands, feet, face, scalp, neck, genitals, and other 
parts of the body. They may develop slowly or rapidly, and per- 
sist for years, or disappear without apparent cause. They may be 
soft, dense, or even corneous to the touch. 

The several names given to the various forms of warts have 
chiefly a descriptive value. 

Verruca Acuminata (condyloma) is a filiform, papilliform, or 
cock's-comb-like vegetation. They are single or multiple ; at times 
hundreds coexist upon the genitalia and neighboring regions. In 
size they vary from a pin's point to a hen's egg, and may be larger. 
They are apt to be moist and secreting, being frequently covered with 
a puriform mucus of exceedingly nauseating odor. Upon the geni- 
tals, they are encountered upon the glaus, around the frsenum, and 
over the prepuce of men ; and in women, about the clitoris, labia, 
vagina, and anus. They are usually of a bright red color in these 
situations. When occurring upon the integument, they are firmer, 
drier, and exhibit a feebler tendency to luxuriant vegetation. In 
this form they may be recognized about the axillary regions, the 
umbilicus, the interdigital spaces of the feet, and even the face. Dr. 
Heitzmann once informed the author that he had seen them covering 
the side of the chin. 

Verruca Congenita and Verruca Acquisita are terms used 
to designate the lesions discovered at birth or later. 

Verruca Filiformis. — This variety of wart differs somewhat 
from the others, not only pathologically, as is noted below, but in its 
clinical features. They are slender, thread-like, often pedunculated 
masses, usually covered with a smooth and apparently unaltered epi- 



382 DISEASES OF THE SKIN. 

dermis, occurring upon the neck, eyelids, chest, and ears of women. 
Kaposi ((includes that they represent minute fibromata. 1 

Verruca Glabra i^ distinguished by its smooth surface. 

Yi:i;i:rcA PLANA is the flattened or globoid, smooth or rugous 
formation like a plaque or button, usually pigmented, and occurring 
upon the back. 

Verruca Senilis vel Plana. — These are bean- to coin-sized, 
smooth, aud softish growths developed upon the face, trunk, and 
extremities of persons of advanced years. They are flat, usually 
pigmented, and have a granular aspect. They are readily separable 
by the finger-nail, and are then found to rest upon a reddish granular 
base. As the result of external injury (caustics, traumatism) they 
may become the starting-point of an epithelioma. 

Verruca Vulgaris is the form most frequently seen upon the 
fingers aud hands, as pin-head to pea-sized, usually discolored, 
papill iform excrescences. 

Of the several varieties of warts it may be said, in general, that 
they are most frequently observed either on the hands or over the 
genital region ; that they are usually discrete but may be confluent 
aud form palm-sized and larger elevated plaques ; that they may be 
soft, hard, smooth, rough, pointed, flat, brush-like, or like the comb 
of a cock ; that they may vary from a pinkish to a blackish hue ; 
that they may persist, occur in crops, or spontaneously disappear ; 
and may grow with great rapidity [Verruca Acuminata] to a large 
size and involve any portion of the body. 

Dr. Fox, of New York, has figured an interesting case in which 
warts occurred in lines tattooed on the skin of a young man. 

Etiology. — The causes of warts are unknown ; but in early child- 
hood, a period in which they are most frequently encountered, it is 
reasonable to conclude that they result from external contacts. It is 
when the child begins to handle everything within reach, that they 
usually first appear, and then about the hands. The acuminate or 
condylomatous warts are chiefly induced in parts moistened with a 
blennorrhagic secretion, but unquestionably may originate from con- 
tact with the leucorrhceal or pathological, non-venereal discharges 
from the female genitals. They are rarely seen in virgins of either 
sex. The senile warts are more probably due to obscure changes in 
the nutrition of the integument. 

Pathology. — Warts on section exhibit, microscopically, an hyper- 
trophy of the papillary layer of the corium concerned in their growth, 
with corresponding development of the vascular loops rising from 
the superior vascular plexus of the corium. Above these papilla? 
the rcte is usually largely developed, the epithelia being multiplied 
not only on the sides of the prolonged papillae, but immediately over 

1 See Dr. Taylor's observations as epitomized in the chapter on Fibroma. 



VERRUCA. 



383 



their apices. In all the dry varieties the stratum corneum is also 
hypertrophied, but this more especially over the summit of the 
excrescence. The filiform warts are composed chiefly of a slender 
fasciculus of connective tissue springing from the bundles below, 



Fio. 




Vertical section of the summit of a pointed wart, a, papilla containing vascular loop ; 
'c, stratum corneum ; d, hypertrophied rete. (After Kaposi.) 

enclosing a vascular loop and covered with an epidermis which is not 
apparently altered. Beneath all forms of warts there may be a sub- 
stratum of sclerosed connective tissue, constituting the firm base upon 
which they rest. - 

The diagnosis of warts is usually readily made, but great care 



384 DISEASES OF THE SK1X. 

must be had to distinguish the moist variety from syphilitic condylo- 
mata. In the latter there is usually a history of contagion with 
other syphilodermata upon the surface, such as mucous patches, 
palmar lesions, or papules of the face. Fibroma, or molluscum 
fibrosum, generally occurs in tumors of greater number, firmer con- 
sistence, and larger size. The tumor of molluscum epitheliale 
greatly resembles a wart, but the waxy-whitish appearance of the 
lesion and its dark punctum at one point or another, sufficiently 
distinguish it. 

Treatment. — Warts may be removed by excision, erasion, or caustics 
(nitrate of silver, alkalies, acids, perchloride of iron, corrosive sub- 
limate, etc.). The larger growths upon the genitalia are often highly 
vascular, and may demand the prior application of a ligature when 
they arc pedunculated. Even the slender filiform warts will be 
found to contain a small vessel in the pedicle which requires cauteri- 
zation after the excision. When the warts cannot be more readily 
removed by the knife or curved scissors, the Paquelin cautery may 
be used. The blackened eschar which is left prevents hemorrhage, 
serves as the best subsequent dressing, and is less apt to be followed 
by a return of the growth. In some cases, it is a useful expedient 
to transfix the lesion iu several directions with the long needles used 
iu gynecological practice, previously dipped iu a fifty per cent, solu- 
tion of chromic acid. 

By far the simplest and most elegant method of removal, however, 
is to transfix the base of the wart a sufficient number of times with 
a needle connected with the negative pole of a galvanic battery, the 
positive being connected with the body of the patient by the aid of 
a moist sponge. 

The formula, accord iug to which are made several of the proprie- 
tary "wart cures" sold in the shops, is as follows : 



R. Acid, salicylic. £ss; 2 

Cannabis indie, extr. grs. v ; 

Collodion Jss; 16 

Sig. To be painted over the wart with a camel's-hair brush. 



M. 



For patches of warts, Van Harlingen recommends attacking one 
part at a time cautiously with the following paste: 

R. Pulv. acid, arseniosi gr. vj ; (40 

Ungt. hydrarg. ) aa q. B. ad 8 

Emplast. hydrarg. j 5ij; M. 

For warts not requiring operative removal, local treatment often 
answers well. Those about the genital region often disappear if 
persistently washed with a solution of tannin in alcohol, one drachm 
(4.) to three ounces (96.), after which they are dried and thor- 
oughly dusted with boric or salicylic acid with lycopodium ; or 
burnt alum and rosin ; or, what is most popular, dry calomel. Alum 
and lead lotions may also be substituted for the tannin and alcohol, 
and for a time kept over the parts as a compress. 



VERRUCA. 385 

Prognosis. — Warts are benignant growths ; and in childhood and 
early adult life need uot suggest grave sequelae. It is far different 
in advanced years, for, though these excrescences possess even then 
no malignant character, they are the too frequent precursors of 
epithelioma. While it may be urged justly that the early lesions in 
such cases were really epitheliomatous and not verrucous ; the fact 
remains that many warty formations of apparently benign character 
do in advanced years, especially under the teasing of frequent cauteri- 
zation, undergo a cancerous transformation. 

Multiple Cutaneous Tumor Accompanied by Intense 
Pruritus. — Under this title Dr. W. A. Hardaway/ of St. Louis, 
describes a rare disorder characterized by the occurrence of about 
sixty pea- to nut-sized, dense tubercles and tumors covered by a 
thickened, scaly, and excoriated, often hemorrhagic skin. In some 
situations coalescence had occurred, forming thus long and narrow 
plaques of nearly the width and half the length of the finger of an 
adult. The lesions were seen upon the outer aspects of the arms 
and legs, the palms and soles, the sides of the fingers, and around 
the ankles, wrists, and elbows. The accompanying pruritus was 
intense and intolerable ; and, having lasted for twenty-two years, 
was naturally associated with the degree of pigmentation often 
observed under similar conditions. The patient was an unmarried 
woman, fifty-one years of age, and declared that the lesions first 
appeared as "blisters." 

Specimens of these tumors, examined by Dr. Heitzmann micro- 
scopically, exhibited hyperplasia of the epithelial and connective 
tissues. The papillse were longitudinally elongated, branching, and 
provided with narrow capillaries. Numerous nests, greatly varying 
in size, and containing inflammatory elements with considerably 
enlarged bloodvessels, lay close beneath the papillary layer of the 
corium. These elements showed all stages of transition into basic 
substance. The deeper layers of the derma were built up of very 
coarse bundles of connective tissue and numerous elastic fibres. 

Papilloma. — This term has been loosely applied to a large 
number of cutaneous growths widely differing from each other, both 
histologically and clinically. It has been made to include the 
vegetations of syphilis, the neoplasms of naevus, and even the tuber- 
cles of lupus. 

The designation, papilloma, is properly limited here to such cir- 
cumscribed hypertrophies of portions of the skin as correspond with 
warts in their pathological significance. They may be defined as 
excrescences from the cutaneous surface, of a size considerably larger 
than all the varieties of the wart with the exception of the condy- 
loma, usually presenting a luxuriant vegetation composed of elon- 
gated papillse, bloodvessels, and enlarged rete, covered externally 
with a smooth epidermis like a pellicle, or, more commonly, branched 

1 Arch, of Derm., April, 1880, p. 129. 
25 



386 DISEASES OF THE SKIN. 

and tufted with the cauliflower aspect, and (hen usually covered with 
a puriform mucus. The tumor increases rapidly till it attains a 
maximum size, and then indolently persists. It is benign in char- 
acter, and bears no relation to struma, carcinoma, syphilis, or lupus. 
It may occur upon any portion of the body. The cases observed by 
the author all occurred in women who were either pregnant or at the 
period of the menopause. 

Verruca Necrogenica. 

Verruca Necrogenica is a vesiculo-pustular or wart-like lesion situated usually 
on the hands, resulting from contact with the bodies of the dead, which 
may induce grave constitutional symptoms. 

This lesion, also known as the " Post-mortem Tubercle," " Dis- 
section Tubercle," or "Anatomical Tubercle," was first named 
by Wilks, 1 verruca necrogenica. It commonly occurs on the fingers 
of those engaged in the habitual handling or dissection of cadavers, 
and is said to result both from such habitual contacts, and also from 
dissection wounds. Cases are reported where the lesion has had a 
non-cadaveric origin. It begins at the site of an abrasion or wound 
as a vesico-pustule, with deep-seated base and reddish or reddish- 
purple areola. This is productive of a burning, smarting, or pru- 
ritic sensation. The lesion accomplishes a period of bursting and 
crusting, which may be followed by complete involution. But when 
the typical so-called "anatomical tubercle" forms, the tissue becomes 
indurated and horny, and a pigmented verrucous papule or tubercle 
very slowly forms, which may become fissured at one or more points. 
The characteristic lesion is the thickened, 
Fig. 46. indolent, more or less pigmented and fis- 

sured, split-pea to bean-sized wart, usually 
single, found on the finger of the auatomist. 
In other cases, grave symptoms result 
either in the involvement of the deeper tis- 
sues (subcutaneous, thecal, tendinous, peri- 
osteal), or in the production of erysipelas, 
3p pya?mia, septicaemia, or gangrene. Surgeons 
divide these cases into mild and acute va- 
Jfl rieties, according to the symptoms exhibited. 

The records of the medical profession in 
almost every one of the larger cities of this 
9 country contain the names of one or more of 
its emineut representatives whose lives have 
been sacrificed in this manner. 

It is probable that some one or more of 
the ptomaines, described on a preceding 
Model P a g e > may be responsible for some of the 
results here mentioned. 

Out of more than fifty-eight thousand 
cases of cutaneous diseases collected by the statistical committee 

1 Guy's Hospital Kep., 3d series, vol. viii., p. 263. 




> 












' 1 




Verruca Necrogenica. 


Guy's 


Mus. 1935». 



NJEVUS PIGMENTOSUS. 387 

of the American Dermatologieal Association, but one instance was 
reported of verruca necrogenica. This does not, however, exactly 
represent the frequency or, better, the infrequency of the lesion, since 
the majority of all such accidents occur in the persons of anatomists 
and surgeons, who destroy their lesions themselves without consulting 
others on the subject. 

The treatment of verruca necrogenica is destruction of the lesion 
with acid nitrate of mercury, nitric acid, or caustic potassa. 

The prognosis is not necessarily grave. 

Nsevus Pigmentosus. 

Lat. ncevics, a mask. 

Nsevus Pigmentosus is a congenital, circumscribed pigmentation of the skin, 
in single or multiple deposits, either with or without textural cutaneous 
change, or associated with the development of warts, plaques, tumors, or 
pilary hypertrophy. 

Abnormal congenital pigmentations of the skin vary in color from 
a light yellow or chocolate-brown to a blackish hue, and may be 
single, or multiple and very numerous. They are commonly termed 
Pigmentaey Moles. They vary in size from a pin-head to tumors 
of considerable volume ; and are either ovoid or circular in contour, 
or so irregularly shaped as to present a fanciful resemblance to parts 
of the figures of the lower animals, whence the popular belief as to 
their origin in maternal impressions. They occur in both sexes ; and 
upon the face, neck, trunk, thighs, buttocks, and external genitals. 
The term Nsevus Spilus is applied to those which occur in a smooth, 
and otherwise unaltered skin ; N^vus Verrucosus, to those which 
are irregular and wart-like; N^vus Pilosus, to those surmounted 
by a growth of shorter or longer, stiff or downy, dark-colored hairs ; 
and Nsevus Mollusctformis, or Lipomatodes, to the soft or firm, 
more or less elevated and projecting tumors. 

They may be, when multiple, symmetrically or asymmetrically 
developed upon the surface of the body ; and in either case may 
exhibit in their arrangement the controlling effect of the nervous 
system. In a case reported by myself 1 there were multiple mono- 
lateral pigmentary nsevi distributed over the left side of the trunk in 
the course of the intercostal nerves, and in such a manner as strongly 
to suggest to the eye their correspondence in site with the lesions 
of zoster of the same region. De Amicis 2 had previously reported 
a somewhat similar case. 

The course of pigmentary nrevi, after obtaining their full evolution, 
is to persist unchanged for a lifetime. Their increase in tender years 
is occasionally characterized by a relative rapidity. The author has 
seen a pilary mevus upon the cheek of an infant extend over nearly 
double its original area in the course of two years. 

1 Chicago Med. Joum. and Exam., October, 1877. 2 Lo Sperimentale, March, 1876. 



388 DISEASES OF THE SKIN. 

The lesions of this Bori seem to occur with equal frequency in the 
two sexes. It is possible that they may be acquired after birth, as 
claimed by some authors, but it is much more probable that such 
presumably acquired cases were instances of rapid development from 
minute congenital pigmentary moles. 

A case of unusually large congenital naevus lipomatodes associated 
with multiple pigmentary uaevi of several forms occurring in a child, 
was observed by the author in 1883, the report of the case made 
subsequently being illustrated by a chromo-lithograph. 1 (See frontis- 
piece.) 

Patholof/y. — Anatomically, pigmentary moles are readily separable 
into two classes: first, those in which the pigment only of the skin 
undergoes hypertrophy (naevus spilus) ; second, those in which both 
epidermis and corium are hypertrophied, forming verrucous, pilous, 
mollusciform, and other lesions. The distinction made by V. Baren- 
sprung, Gerhardt, and others, between these two classes and still a 
third, where the lesions are limited to the cutaneous regions supplied 
by one or several nerves (Nsevus Unius Lateris, Papilloma Neuropath - 
icum) is more apparent than real : for a close study reveals a tropho- 
neurotic influence exerted in all cases, even in the enormous tumors 
of a mollusciform type. According to Demieville, the pigment 
accumulation occurs in the corium as well as in the epidermis, in the 
form of ribands stretching along the lines of the bloodvessels. 

Pigmentary moles very rarely disappear spontaneously. Their 
removal may be accomplished by excision, or by destruction with 
caustics, with the Paquelin knife, or with the needle by electrolysis. 
The last-named method is applicable only to the smaller and more 
superficial growths of this class. Fox 2 calls attention, in connection 
with this subject, to the need of passing the needle no deeper than 
the epidermis, sufficiently deep merely to " blister the surface of the 
black spot." 

Xerosis. 

Gr. Zwpoc, dry. 

Xerosis is a congenital dryness and roughness of the epidermis accompanied 
by a moderate degree of furfuraceous exfoliation. 

Xerosis, also termed Xeroderma, is a term which has been 
applied to the disease sometimes known as xeroderma pigmentosum, 
or the melanosis lenticularis progressiva of Pick. In these pages that 
disorder is described, in accordance with the nomenclature of the 
American Dermatological Association, as angioma pigmentosum et 
atrophicum. 

The term xerosis, or xeroderma, has also been employed to designate 
a simple asteatosis. It is also used by some authors as practically 
equivalent to ichthyosis. It is sought here to limit its application to 

1 Jonrn. of Cutan. and Vener Diseases, July, 1885. 

2 Electricity iu ltemoval of Superfluous Hairs, etc., Detroit, 1886. 



xerosis. 389 

the description of a distinct and easily distinguished morbid condition 
of the integument. 

Symptoms. — The sole symptoms found in xerosis are cutaneous. 
The skin of the body, in some regions more than others but at*times 
universally, is to the touch of another, dry, harsh, rough, and desti- 
tute of natural moisture and unguent. Closely inspected, the surface 
is seen to be scaly, the exfoliation being of the character described as 
furfuraceous. In some cases the hand passed briskly over the surface 
of such a skin will cause a moderate separation of a few of the scales 
in a scanty shower ; in yet others, while the surface seems quite fit 
for the furnishing of such free flakes of epidermis, one is surprised to 
note that the free flakes are more or less attached, and the clothing of 
the patient is not, as in some forms of psoriasic and pityriasic disease, 
covered with epidermal scales. In brief, there is not in progress a 
catarrh of the horny layer, as in some of the other disorders named j 
but merely an unusual keratinic transformation of the elements of 
that layer. 

The parts chiefly involved are the extremites, more particularly 
the hands, feet, forearms, and legs ; but all parts of the skin may be 
involved, including the face, temples, cheeks, and even the lips. 

The disorder is met with in all grades, from the mildest physio- 
logical dryness of the skin, almost suggestive of the so-called "goose- 
flesh," to that state in which the exhibition of the face only, suggests 
an abnormal condition of the skin. The color of the latter in well- 
marked cases is always of a dirty yellowish or dirty brownish shade, 
suggesting the unwashed condition of the integument, and in extreme 
cases of older patients becomes rather deeply pigmented. It is seen 
in both sexes and at all ages, being a congenital condition whose first 
appearance is only clearly indicated after variable periods of time after 
birth. Red-haired individuals perhaps furnish the larger number 
of well-marked cases. The general health is unaffected. Before 
puberty the affection, in northern latitudes, will often be inappre- 
ciable in summer, and distinct in winter. As maturity is reached, 
however, the condition becomes more or less permanent. 

This disorder may be, as described by some authors, a variety of 
ichthyosis simplex, but the following are excellent reasons for giving 
it a separate consideration : 

1. The disease does not furnish the typical plate-like scales of 
ichthyosis. 

2. One child affected with what appears at first to be merely 
xerosis, may exhibit a typical ichthyosis before puberty, while an- 
other will go through life, the xerosis of his childhood becoming 
simply the exaggerated xerosis of mature years, but never an ich- 
thyosis. 

Xeroderma may therefore be regarded in one sense as a variety of 
ichthyosis, but cannot be described as a stage of the latter disease. 

The disorder is congenital, and may be inherited from parents. 
It is readily distinguished from all furfuraceous scaling diseases of 



390 DISEASES OF THE SKIN. 

the skin by the absence of inflammation. The treatment and prog- 
nosis are those of the disease next considered. 

Ichthyosis. 

Gr. iipdb?, a fish. 

Ichthyosis is a congenital deformity of the skin, developed first in early 
infancy, and manifested in a general scaliness, in the formation of regularly 
outlined polygonal plate?, or in the growth of larger masses of a corneous 
consistency. 

Symptoms. — The disorder, also termed the "Fish-skin Disease" 
and ''Xeroderma/' is one which displays a wide variation in its 
symptoms. To the extremes in either direction two names are given, 
ichthyosis simplex and ichthyosis hystrix. 

Ichthyosis Simplex. — The earliest and mildest form of ichthy- 
osis simplex is, by many authors, held to be the condition of xerosis, 
fully described in the preceding pages. It will be remembered, 
however, that such a xerosis may persist through life without the 
production at any time of the peculiar symptoms of the ichthyotic 
skin. In these earlier manifestations of the disease then, the skin of 
the patient can merely be described as unusually harsh to the touch, 
moistureless, and covered with adherent or exfoliating, fine scales. 
The latter are not massed, imbricated, nor displayed in plaques, and 
are usually of a dull yellowish-white color. It is rare that the prac- 
titioner is consulted for the relief of this disorder ; it is usually discov- 
ered when the skin is exposed for other purposes (exploration, vac- 
cination, etc.). In a still more advanced degree, the scales are 
massed together, forming grayish and whitish, polyhedral elevations 
or plaques, regularly outlined and closely set together, especially 
upon the extremities and certain portions of the trunk. Elsewhere 
the scaliness described above may be present in a more marked 
degree. Variations occur, in consequence of which the plaques, 
bordered distinctly by the natural lines and furrows of the skin, are 
even depressed, centrally or completely, or assume darker shades of 
color than those described, brownish and greenish-brown. 

Ichthyosis Hystrix. — With and without the symptoms detailed 
above, the hypertrophy of the skin may, in circumscribed patches or 
larger areas, produce irregularly shaped, verrucous, corneous, corru- 
gated, wrinkled, or rugous masses, usually much darker in color than 
the patches seen in the simple variety of the disease, aud more often 
also discovered in adult years. The resemblance is here rather to 
the rough bark of a tree than to the scales of a fish. In other still 
rarer cases, the excrescences assume a spinous, acuminate, or horn- 
shaped form. The hand passed over the surface perceives not only 
the excessive roughness, but also the dryness of the skin. Perspira- 
tion is imperceptible in the parts affected. The nails are friable 
and indurated ; the scalp scaly, aud covered with hairs of exceeding 



ICHTHYOSIS. 391 

harshness. The palms and soles are often spared Kaposi described 
certain diffuse callosities occurring in the palmar and plantar regions 
differing from the ichthyotic patches elsewhere. The face is usually 
spared, but, when involved, only the slighter manifestations of the 
disease appear there, minute, superficial, scaly patches of a grayish 
tint. 

Ichthyosis is accompanied by insignificant subjective sensations. 
The skin, indeed, of these, patients seems inapt for the eczematous 
and other complications of the less diffuse keratoses. The author 
has treated four ichthyotic patients for syphilis, and noticed in all a 
decided tendency to the production of lesions of the mucous surface 
without cutaneous efflorescence. The extensor are usually more 
implicated than the flexor surfaces of the extremities. 

Singular variations from the types described above are noted by 
observers. Hilbert, 1 for example, in a case of congenital circum- 
scribed ichthyosis in a young woman, discovered a growth of thick 
hairs over the left shoulder and arm, one centimetre long. Weisse 2 
exhibited to the New York Dermatological Society a boy, ten years 
old, with hemorrhagic fissures in an ichthyotic skin, double ectropion, 
corneous opacities, claw-like fingers, attachment of the ears to the 
sides of the head, and a generalized condition of the skin, which 
became very red when warm, some doubt, however, existing as to 
the diagnosis. 

The most exaggerated types of ichthyosis are seen in the so-called 
"Porcupine," " Rhinosceros," or " Hedge-hog" patients. In these 
unfortunate beings, the entire skin is converted into a rugged, 
bristling, warty, quilled, or horn-like envelope, suggesting the integu- 
ment of the animals named. Such conditions are represented by 
Mr. Henry Baker's case, described by Anderson. 

The terms, Ichthyosis Serpentina, Nacrea, Nigricans, are employed 
to designate those conditions respectively in which is recognized a 
snake-like appearance of the skin, silvery whiteness of the scales, or 
a dark pigmentation. 

Viewing the disorder as thus in various ways exhibited, it is seen 
to be a congenital deformity rather than a disease. It may be par- 
tial or general, though usually the latter, with intense manifestations 
over the extremities, especially over their extensor aspects, and 
relative immunity of the face, axillee, groins, flexor aspects of the 
limbs, the palms and soles, the glans penis, and prepuce. 

Like xerosis, the deformity is rarely visible at birth, but usually 
becomes apparent before the completion of the first year of life. It 
is first manifested in the region of election named above — i. e., over 
the elbows and knees — and here also, as in xerosis, may be for some 
years only apparent in this latitude in winter, disappearing almost 
wholly in the summer season. In maturity, the deformity has been 
known to disappear also temporarily under the influence of inter- 

1 Virchow's Arctaiv, Bd. 99, Sept. 3, 1884. 2 Journ. of Cutan. and Yen. Dis., 1883, p. 49. 



392 DISEASES OF THE SKIN. 

current disease (variola). One patient is said to have regularly cast 
a slough of his integument in the autumn. 
The general health is usually unimpaired. 

Ichthyosis Congenita. — This exceedingly rare deformity occurs 
as an intra-uterine modification of the skin of the foetus, which is 
usually brought into the world as a non-viable monstrosity. The 
skin is represented by a thick, horny cuirass, deeply furrowed, and 
resembling plates of armor. The ears, lids, and lips are usually 
wanting, and replaced by corneous folds suggesting in appearance 
the corresponding features of a mummy. The fingers and toes 
resemble talons and claws. Death usually occurs in the course of a 
few days from both inability to secure nutrition by the act of 
sucking, and by imperfect development of other organs than the 
skin. 

Etiology. — Ichthyosis is unquestionably a congenital disease, though 
its first manifestations are only apparent during the second year of 
life. It is said to be generally hereditary, but this should be 
accepted with some reserve for every individual case. One of my 
ichthyotic patients was married to his own cousin, and had by her 
five children entirely free from cutaneous disease. Xone of his 
parents or grandparents was similarly affected. The disease occurs 
equally in both sexes, and is liable to aggravation in cold climates 
and the season of winter. The general vigor and development of 
patients thus deformed are, as a rule, quite unimpaired. Kaposi 
says : " The cause appears to be a local anomaly of the nutrition of 
the skin, especially involving its epidermic and fatty elements;" but 
this scarcely meets the requirements of etiology. 

Thost 1 describes ichthyosis occurring in four generations. Ac- 
cording to the ascertained genealogy, the ancestor first known to 
have suffered from this affection had five male children who inherited 
it, while one girl and one boy were spared. One of these diseased 
children had himself five children, of whom three males showed the 
disease, while one boy and one girl remained free. Another brother, 
of the second generation, had five male and three female children; 
of these, four boys and two girls became affected. One of the latter 
(of the third generation) bore four children, of whom three girls 
inherited the disease, while the fourth, a boy, escaped. It appeared 
that the affection always showed itself within a few weeks after 
birth, in the form of a roughness of the palmar and plantar sur- 
faces. With the growth of the patient, the condition constantly 
increased in severity, the epidermis shedding in large shreds until 
the disease reached its maximum by the fourteenth year. There was 
a marked disposition to excessive sweating, particularly in the dis- 
eased localities; the sensibility of the skin remained normal. Micro- 
scopic examination showed, in addition to the hypertrophied papilla?, 

i Inaug. Diss. Heidelberg, 1880; CM. f. Chir., Xo. 10, 1881. 



ICHTHYOSIS. 



393 



great development of the sweat glands, with marked thickening of 
the ducts. Treatment failed to give more than partial relief. 

In the Molucca Islands and some other isolated regions, ichthyosis, 
on account of its unusual prevalence, has been regarded as an 
endemic affection. But instances of this kind are readily explained, 
without referring to climatic influence, by the operation of the laws 
of heredity with intermarriages. 

JFig. 47. 




Ichthyosis hystrix, vertical section ; a, masses developed from the stratum corneum ; 6, cones formed 
hy the rete ; c, hypertrophied papillae with dilated vessels ; d, dense connective tissue of corium, 
exhibiting numerous vessels transversely divided. (After Kaposi.) 



Pathology. — The diseased, or, better, deformed, skin is found 
microscopically to be hypertrophied in various degrees according to 
the development of the malady, the proliferation of its elements 
occurring in connective tissue, papillae, stratum corneum, and blood- 
vessels. In well-marked cases of ichthyosis hystrix, the elongated 
papillae are surmounted by dense cones of the horny layer of the 
epidermis, more or less concentrically disposed, with sclerosis of the 
connective tissue, and a relatively unchanged rete. Iu this last 
particular, the dense plaque of ichthyosis differs in texture from the 
wart. 

The polygonal ichthyotic plates are composed for the most part of 



394 DISEASES OF THE SKIN. 

corneous epidermal cells, their long axes parallel with the surface of 
the skin, with an unusual accumulation of pigment granules between 
the strata. The interpapillary coues are enlarged; the horny layer 
greatly thickened, the hair-follicles indurated, the papillae elongated 
but not branching, and their bloodvessels dilated. The sebaceous 
glands are frequently converted into cyst-like bodies, the coil-glands 
distended, and the panniculus adiposus diminished in size. 

Diagnosis. — Ichthyosis not only presents features which are so 
characteristic as to be unmistakable, but also those which can be well- 
nigh perfectly portrayed in plates. In this respect it differs from a 
long list of cutaneous maladies. 1 

Whenever necessary, aid of an important character can be gained 
in the history of the disease and in the entire absence of the lesions 
and lesion-sequela?, exhibited in the exudative *md scaling affections 
heretofore considered. The most conspicuous characteristic of ich- 
thyosis, as distinguished from psoriasis, lichen ruber, and pityriasis, 
is the absence of inflammatory phenomena. 

Treatment. — The younger the patient applying for relief, the larger 
are the chances of improvement and possible recovery. Ichthyosis 
hystrix of mature years is practically incurable. Internal treatment is 
valueless. External treatment is directed to softening, macerating, or 
anointing the skin, and, as fir as practicable, preserving it in a softer 
state. This is accomplished by frequent baths, alkaline, vaporous, 
or combined with the use of soap or green soap, and generally fol- 
lowed by an anointing with vaseline, dilute glycerine, or lard. The 
French, after the removal of the denser layers of the horny plates by 
the aid of soft soap and water, anoint the body by friction with the 
glycerolate of starch. Almond, cod-liver, neat's-foot and linseed oils, 
or lanoline may be used after the bath. Only by the most assiduous 
perseverance is a desirable result obtained and permanently secured. 
In the severer hystrix varieties, the most annoying projections and 
rugosities may be removed by excision, the Paquelin knife, or, less 
preferably, by the aid of caustics. 

Subcutaueous injections of one-third of a grain (0.022) of pilo- 
carpine have been practised in ichthyosis, in order to induce sweating, 
with a view to the maceration of the skin. Van Harliugen recom- 
mends the following for use when the epidermis begins to shed after 
the external application of soft soap: 



R. Potass, iodid. J}j ; 1 

01. pedis bubuli ) .. ? , fl 



;;;: 



Adipis 

Glycerin. 5j ; 4 M. 

Anderson recommends the wearing of pure vulcanized India- 
rubber garments, a method of treatment which the author has found 
too exhausting for all cases. 

Taking a general survey of the therapeutical management of ich- 

1 Tho admirable representation of the ichthyotic Bkin in plate !•'. nf Duhring's Atlas, is faithful in 
its exactness. 



ONYCHAUXIS. 395 

thyosis and its results, the course to be advised for the majority of 
patients is very clear. With but few exceptions 1 the subjects of this 
deformity are either entirely relieved, or greatly better in hot weather 
and moist atmospheres. Under these circumstances, and having 
regard to the essential fact that the deformity is life-long in duration, 
patients should always, when practicable, select for permanent resi- 
dence a climate most conducive to the comfort of the skin. There 
is no step which the ichthyotic patient can take at all comparable in 
value with the important selection of a suitable environment. 

Prognosis. — Having in view the facts set forth above, it will be 
clear that in no case can a favorable result be anticipated with respect 
to a "cure" of the deformity. Treatment, persistent, prolonged, and 
properly directed in connection with suitable climatic influences may 
do much to improve the condition of the skin. 

Onychauxis. 

Gr. bvv%, a nail ; av^eu, to grow. 

Onychauxis, or Hypertrophy, of the nails is an abnormal development of 
these appendages of the skin in any diameter. 

Symptoms. — The nail substance may be developed to an unusual 
extent either as an idiopathic or symptomatic affection, and in each 
case may be simply increased in volume, extent, or number, or 
exhibit such increase in connection with secondary changes. Thus 
the nail may develop to an extraordinary length or breadth, pre- 
serving its general character as regards texture, color, and position; 
or it may also be changed in auy particular, becoming opaque, dis- 
colored, dirty yellowish, aud blackish or brownish ; rugous, furrowed, 
horny, and rigid; thickened in one part and thin, vitreous, and ex- 
tremely fragile in another; tilted to one side or another on its bed ; 
or projected backward in recurved, irregular lines. Finally, the 
matrix may be inflamed, suppurating, hemorrhagic, and the seat of 
an excruciating pain. One or more of the nails may be affected; in 
some cases the entire twenty are similarly involved. 

The diseases in which these changes occur as symptomatic lesions 
are numerous, since it is evident that the matrix, from which the 
nail is produced, would scarcely enjoy immunity in the case of pro- 
found alteration of the skin in its vicinage. Thus eczema, lepra, 
psoriasis, lichen ruber, syphilis, scarlatina, perforating disease of the 
foot, variola, and other diseases are attended by changes of various 
grades of severity in both matrix and nail. 

The condition termed Paronychia, is that in which one or both 
lateral borders of the nail bury themselves deeply in the tissues 
adjacent, producing thus an exquisitely tender and painful state of 
the soft parts, which may suppurate or surround the attached limb 
of the nail with exuberant granulations. This is more frequently 

1 While these pages are in preparation, the author has been consulted by an intelligent patient who 
positively asserts that her ichthyosis is always aggravated by warm weather. 



896 DISEASES OF THE SKIN. 

observed in the nails of the toes, as the appendages of the skin are 
liable to injury from the pressure of ill-fitting boots, gaiters, and 
shoes. In the condition described as Onychia, the matrix is not 
only inflamed, bat the nail substance is, as a consequence, texturally 
changed. No strict line of demarcation, however, can be described 
between tli« L two conditions. The term Oxychogrypiiosis has been 
employed to describe the contorted deformities which cause it to 
resemble a claw. 

Onychomycosis is the name given to that condition in which the 
nail substance is invaded by vegetable parasites. In such cases, the 
nails become opaque, discolored, and thickened, with a noticeable 
friability at the projecting border. 

In Syphilitic Onychia, one or several of the nails may become 
affected, though it is quite characteristic of the disease to exhibit 
limitation to the extremity of a single digit. In such cases, there is 
usually a very marked involvement of the peripheral soft parts, 
which may be infiltrated with gummatous material. The bullous 
syphiloderm, of the congenital manifestations of the disease, will at 
times form beneath or quite near the nail, and thus endanger its 
integrity. In both forms, ulcerative results are common, with secre- 
tion of a foul discharge. 

In the affection termed perforating disease of the foot, all the 
nails of the feet may exhibit a characteristic onychauxis. 

Traumatism (constant or intermittent pressure of shoes) may 
augment the size of the nail in one or another diameter ; and the 
deformed talons resulting from gross and long-continued neglect 
(East Indian devotees, etc.) are illustrations of another type of hyper- 
plasia. Supernumerary nails may be found on supernumerary 
fingers and toes; or double organs on a single digit; or in unusual 
situations as over the scapula (Tulpius) ; or on a digital stump ; or 
in an ovarian cyst. 

With respect to onychauxis proper, two forms are recognized. In 
the first, the nail-cells are more closely set together and the resulting 
hypertrophy is declared, not in changes in bulk of the nail, but in a 
dense, thick, opaque, glossy, grayish-white transformation of the 
organ. It is perceptibly increased in weight and becomes so solid 
that it cannot be cut by ordinary implements. It may be also, 
though not changed in bulk, altered in shape, its free border curved 
downward or upward. 

The second form represents a visible hypertrophy iu bulk, the nail 
being enlarged in one or several diameters. Enlargement in a trans- 
verse diameter necessarily involves the soft parts adjoining. Vertical 
hypertrophy results in any one of the claw- or talon-like forms of 
onychogryphosis. 

Etiology. — Onychauxis may be congenital or acquired ; idiopathic 
or symptomatic ; and due to inflammatory changes in the corium or 
matrix of the nail ; to traumatism ; to defective hygienic care of the 
general surface of the skin including the nails; and, perhaps, in 
exceptional cases, to senile influences. 



ONYCHAUXIS. 397 

Pathology. — According to Geber, there is in gryphotic nails a 
tolerably uniform consistence superficially ; and in the deeper strata 
a harder or softer substance arranged in fan-like layers. In the 
former region, the nail is made up of small, roundish, or flattened 
cells containing variously sized dark granules. These have a linear 
arrangement along the longitudinal axis, and, in places, as along the 
higher transverse ridges, are more closely aggregated. More deeply 
the cells are irregularly grouped. According to Virchow, they con- 
tain, centrally, horizontal masses of horn, which descend laterally, 
including the so-called " medullary spaces." These are sharply 
defined loculi filled with a homogeneous, lustrous, yellow, or finely 
granular mass ; and in them may be found epidermal cells in process 
of keratinization. 

When the nail is lifted off, the bed looks short, arched, and 
narrow. Beneath the epidermis accumulated upon the surface, the 
hypertrophied ridges, longitudinally arranged anteriorly, and the 
papillae more particularly, become visible, the latter containing large 
vascular loops surrounded by a small-celled infiltration. 

Treatment. — The treatment of the disorders of the nail described 
above, is largely that of the maladies in which they occur. Arsenic 
and iron are often indicated in these affections ; and their influence 
upon the nutrition of the nail cannot be questioned. In syphilitic 
onychia, the constitutional treatment of the disease is essential. The 
cutting, scraping, and trimming of the nail by the aid of the useful 
instruments found in the chiropodist's case, supplied by most surgical 
instrument makers, are important measures in many cases. 

The treatment of ingrowing toe-nail varies with the extent of the 
disease. In mild cases, soft threads of charpie are insinuated between 
the offending border of the nail and the tender granulating surface 
upon which it presses. Counter-pressure by plaster and the local use 
of the crayon of nitrate of silver, may be at times employed with 
advantage. In severer cases, the nail may be removed, though this 
is generally unwise. The method of treatment devised by Agard, of 
California, often produces the speediest results. The soft parts are, 
by him, completely removed from the side of the nail by means of a 
thin-bladed bistoury ; and the nail permitted to grow down upon 
one side of the extremity of the distal phalanx, thus protecting the 
cicatrix and radically preventing the recurrence of the disease. 

The proper dressing of the feet in onychauxis of the toes is a 
matter of great importance. The shoes and socks, or stockings, 
should be adjusted both as to texture and shape to the special 
requirements of each case. After the hypertrophied tissue is largely 
removed by cutting or scraping, the phalanx may be enveloped in a 
plaster-mull or salve-muslin of diachylon ointment, or with mercurial 
plaster, and the whole covered with a leather or rubber cot. 

The Prognosis in these disorders of the nails rests entirely upon 
the nature of the malady in which they occur. Idiopathic and 
localized changes, as also those occurring in transient cutaneous dis- 
eases (e. g. the exanthemata), often terminate favorably. In severe 



398 DISEASES OF THE SKIN. 

constitutional or grave cutaneous diseases, the outlook is less promis- 
ing. The diseases of the nail are usually more obstinate and less 
amenable to treatment than the similar affections of the softer parts. 
In cases where there is congenital disease of the nails, a prognosis 
should be made with reserve. 

Hypertrichosis. 

Gr. birkp, in excess; 0p\%, hair. 

Hypertrichosis is a development of the pilary filaments, exaggerated as to size 
or Dumber, or unusual either with respect to the location of the growth, or 
the age, or sex, of the individual in whom it is displayed. 

Hypertrichosis, Hypertrophy of the hair, Hairiness, or Hirsuties, 

may be congenital, and this in various grades. It is sufficiently 
common to see infants at birth provided with extremely long hairs 
of the hairy parts of the body, such a growth being usually replaced 
later by shorter filaments. Universal congenital hirsuties is a rare 
deformity, the entire body being then covered with longer or shorter 
downy hairs of various colors. 

Acquired hirsuties may be partial or universal, much more com- 
monly the latter. Thus the hairs of the scalp or beard may acquire 
an enormous vigor and length, reaching fully to the ground when the 
figure is in the erect position; or the hypertrophy of the hairs may 
affect the face of the child or woman, and in this sex, either the upper 
lip, chin, cheeks, or all [tortious of the body usually covered by hairs 
in mau, be provided with a vigorously and symmetrically developed 
pilary growth. 

Remarkable instances of universal congenital hirsuties are occa- 
sionally observed. The so-called "Russian dog-faced mau" (Andrian 
Jeftichjew) and his son, lately on exhibition- in this country, were 
noteworthy illustrations of this anomaly. In most cases the influence 
of heredity is usually distinct and often accompanied by defective 
dental development, such as entire absence of molar or canine teeth. 
In all cases of hypertrichosis, whether congenital or acquired, the 
parts normally unprovided with hair, such as the palms, soles, ungual 
phalanges, prepuce, glans penis, upper eyelids, and vermilion border 
of the lips, are not the seat of the pilosis. 

As the growth of the beard in man is more or less associated with 
the maturity of the sexual organs, so we often find the hypertrichosis 
of women and children related to a precocious, perverted, or arrested 
function of the generative organs. The reported instances of men- 
struation in female infants and children usually include a description 
of abnormal pilary development about prematurely developed 
pudenda ; and after the climacteric period, when some women con- 
spicuously begin in external appearance to resemble individuals of 
the opposite sex, either isolated, thick, bristle-like hairs develop over 
the chin or lips ; or the extreme hirsute condition may be reached. 



HYPERTRICHOSIS. 



Duhring 1 has reported one such case, which is illustrated by an excel- 
lent lithograph representing the face of a woman provided with a 
superb beard. 



Fro. 48. 




The Russian "Dog-faced Man." 

The influence of the sexual organs in the hypertrichosis of women 
is well demonstrated in the following case coming under the author's 
observation. 

A married woman, thirty-three years of age, weighing one hundred 
and fifty pounds, mother of three healthy children, applied, in 1883, 
for relief of a general and facial hirsuties which had resulted in the 
growth of a full beard and moustache. She had not menstruated for 
more than a year, and had been pronounced by an expert past the 
climacteric. During the years 1884 and 1885 the author removed in 
successive operations the hairs of the face by the electrolytic method 
described below. Menstruation began while she was subject to the 
influence of the galvanic current in the operating-chair, and continued 
thereafter irregularly, at times with intense pain and even menor- 
rhagia. In 1886, after the last of the operations on the face, she 
rather suddenly lost in weight, decreasing to one hundred pounds, 
and began to menstruate regularly and painlessly. The hyper- 
trichosis of the general surface then disappeared by a simple fall of 
hair. In the latter part of the year she again conceived, and in 

1 Arch, of Dermatology, April, 1877. 



400 DISEASES OF THE SKIN. 

March, 1887, beiug then quite free from any form of hirsuties, she 
brought a healthy male child into the world. 

As the result of the local application of stimulating and oily lini- 
ments persistently and over a single region of the body (scapula, 
sacrum, sciatic notch, etc.) a growth of long and numerous hair- i- 
often produced. Care should be had in the management of cases of 
acne and rosacea in the persons of dark-skinned young women with 
luxuriant hair upon the head, lest this growth be precipitated upon 
the chin, cheeks or nose. 

In cases of hypertrichosis the hair- may be variously colored, and 
the hypertrophy of downy hairs be purely numerical, or result in 
increase in the actual size of the shaft of the individual filaments. 
In neither case do the hairs present any anatomical peculiarities of 
structure. The localized congenital form of hirsuties is often charac- 
teristic of certain moles, known as N.evi Pilosi ; and the surface of 
pigmentary moles (N.evi Pigmextosi) is often very extensively 
covered with hairs of a dark color. Singular anomalies have been 
figured by a number of dermatologists where extensive regions (one 
or several limbs, the entire back, even the greater part of the body) 
were the seat of enormous pigmented moles, covered with warts, 
fibromata, and other benign tumors, and clothed with a thick 
covering of longer or shorter hairs. 1 All such cases exhibit a striking 
development in either symmetrically or asymmetrically disposed areas 
of distribution of cutaneous nerves. 

Under the name Plica Poloxica was formerly described, a condi- 
tion supposed to be a disease peculiar to the Poles (whence its name), 
but which has long been recognized as a result merely of persistent 
neglect, filth, the invasion by parasites, and consequent exudative dis- 
orders of the scalp. When it exists, the hairs form a huge matted 
mass on the crown of the head. Hebra has devoted some interesting- 
pages to the superstitious awe with which this accumulation of hairs, 
lice, and filth has been regarded. Dr. H. M. Bannister, lately con- 
nected with the U. S. station in Alaska, informs me that he has 
seen a number of cases of plica among the natives of that region. 
A typical case of this curious deformity was lately presented at the 
author's clinic. 

Under the title Xeukopathic Plica, Le Page 2 describes a case in 
which tangled "lumps" and "festoons" of hairs, flat, curled, looped, 
and intertwined, appeared on one side of the head of a girl seventeen 
years old, who had previously suffered from neuralgic pains in the 
site of the growth. 

Etiology. — The causes of hypertrichosis are practically unknown. 
It is clear that whatever determines the blood in excess to any one 
region of the body, may be indirectly the cause of hypertrophy of 
the hair, a fact demonstrated in the patients who, after applying 
sinapisms or liniments for years to the skin over the seat of a rebel- 

1 See the author's case of nrcvns lipomatodes in a child, the pilary growth being at that age unde- 
veloped. Journal of C'utan. and Ven. Diseases, July, 1885. 

2 British Medical Journal. January 20, 1884, p. 160. 



HYPERTRICHOSIS. 401 

lions neuralgia, exhibit an abundant growth of hair, often several 
inches in length, over a scapula or a buttock. In women, whose sex 
renders the anomaly most deforming and distressing, it is chiefly noted 
as has been observed, in precocious, perverted, or arrested activity 
of the sexual function. The neurotic conditions accompanying 
certain varieties of hirsuties may be inappreciable ; or evidently due 
to traumatism ; or exhibited in paralyses, muscular atrophy, etc. 

Treatment — To Hardaway, of St. Louis, Americans are indebted 
for the popularization of the method of removing superfluous hairs 
by electrolysis, first devised by Michel, of his city. 'After him most 
American dermatologists have with success removed extensive pilary 
growths without subsequent reproduction of the hairs. A fine needle 
is introduced into the hair- follicle and pushed well down to the 
papilla at its base. This instrument is connected with the negative 
pole of a galvanic battery containing six or more elements, the posi- 
tive pole of which is in connection with a sponge electrode held in 
the patient's hand ; the latter being thus enabled to make or break 
the circuit at will. When the current is passed, a few minute 
bubbles of gas escape from the orifice of the follicle, and, when the 
hair-papilla is destroyed, the hair itself is readily extracted. The 
dexterity acquired by practice is requisite for the proper performance 
of the operation, with a view particularly to the insertion of the 
needle at the proper angle into the follicle. Few patients complain 
of pain. The number of hairs removed at a sitting varies with the 
sensitiveness of the patient's skin. The resulting scar is either 
quite imperceptible or far less disfiguring than the hirsuties, sug- 
gesting the appearance of the male beard after shaving. Transitory 
maculae, papules, pustules, and wheals occur at the site of puncture. 
Care should be taken not to insert the needle too deeply in the par- 
ticularly vascular regions of the face, as an aneurismal tumor might 
be produced as a consequence. 

Every detail of this exceedingly simple operation has now been 
carefully studied by American operators, and the results, as con- 
firmed by the author's experience, may be given as follows : 

1. As to the battery, any good galvanic battery may be employed. 
The author uses habitually the forty-cell stationary battery made by 
the Mcintosh Galvanic and Faradic Company, whose switch- board 
is so arranged that any number of any selected cells may be brought 
into the circuit. The number of cells employed should be different 
for different individuals, different parts of the face, and on different 
days with the same individual — e.g., a smaller number is required 
when a patient previously operated upon returns after a somewhat 
long period of rest. Two to four cells only may be tolerated over 
the tip of the nose or upper lip near the septum nasi. Twelve to 
twenty may be well borne, after some experimenting, on an insensi- 
tive chin. 

2. The best needle is a carefully selected, exceedingly fine jeweller's 
broach, its shaft and point annealed by rapid passage through the 
flame of an alcohol lamp. It is often useful to have the point also 

26 



402 DISEASES OF THE SKIN. 

well rounded on an emery-wheel. The irido-platinura needles are 
useful, but inferior for general work to the well annealed, carefully 
selected broach. 

3. The needle-holder should be simply a convenient insulated 
handle, sufficiently long to protect all the points of the operator's 
right hand from the current. The author employs Prof. White's 
long handle. Duhring's 1 is of the shape of a thin lead pencil or pen- 
holder, and is about four inches in length. The handle or stem is of 
hard rubber, through which passes a metallic rod, acting as a con- 
ductor for the transmission of the current. The needle is inserted 
into the needle-holder proper, which is slolted, the needle being 
clamped immovably by means of a screw-nut. On the other end of 
the stem there is an insulated inserting-pin attached to the cord 
leading to the battery. The instrument is of proper weight, conve- 
nient to handle, and altogether well adapted for the operation. 

4. As to further details of the operation it is well (a) to make the 
connection only after the needle is in situ; (b) to introduce the latter 
with a gentle manipulation acquired only by skill — it is well charac- 
terized by Hard away as a "catheterization" of the hair-follicle — 
observing a certain degree of parallelism with the hair-shaft as the 
needle enters ; (c) to operate leisurely, making sure that the current 
is not broken by the separation of the hands of the patient, before the 
hair is completely free in the follicle. This last can be ascertained 
by gentle traction on the shaft in from ten to twenty seconds after 
the insertion of the needle ; (d) to operate in succession upon con- 
tiguous hairs when practicable, not selecting one here and one there, 
the latter course being productive of greater pain ; (e) never to use 
the positive pole in connection with the needle, an error which results 
in the production of unsightly pigmented blemishes on the surface 
of the skin. 

The previous employment of preparations of cocaine both hypo- 
dermatically and by inunction — c.r/., the oleate of cocaine — in order to 
relieve or diminish the pain of the operation, may be followed by 
exceedingly unpleasant consequences. The author has seen a derma- 
titis thus induced present for months. 

Dr. Prince, of Boston, 2 lays stress upon the accurate regulation of 
the current by the aid of the absolute galvanometer, which the author 
has found in his practice useful but not essential. Dr. Fox, 3 of 
New York, reports a gradual decrease in the number of hairs 
returning after operation, proportioned to the improvement in the 
instruments and skill of the operator. There can be no question that 
the percentage of such returns varies with these conditions. 

All patients affected with hirsuties are not to be advised the opera- 
tion. The author has declined to operate in many cases which were 
not deemed to belong to the class in which the best results of the 

1 Amer. Journ. of the Med. Sci., July, 1881. 

2 The exact measurement of the electric current, and other practical points in the destruction of 
hair by electrolysis. 

3 The usl> of electricity in the removal of superfluous hair, etc. Detroit, 18S0. 



H YPERTRICHOSIS. 403 

operation may be expected. Young and vigorous women, usually 
unmarried, may point out hairs to be removed which are merely 
fully developed filaments of a thick downy growth, all of whose 
individuals are rapidly pushing to equal maturity. Here the opera- 
tion itself, by inducing hyperemia of the skin, may simply hasten 
the hypertrichosis actually in progress, and thus aggravate the. dis- 
order. In most cases when an operation is undertaken, both parties 
should fully understand the possible issue. It may also be a ques- 
tion whether it lies within the legitimate sphere of the physician to 
remove superfluous hairs from the habitually covered breast and arms 
of women. 

Hairy naevi are best removed by complete excision. 

Depilatories for the removal of superfluous hairs operate by the 
destruction of the filament without obliteration of the papilla. The 
consequence is that the hairs are reproduced in the course of about 
a fortnight. Most of the compounds used for this purpose contain 
either the sulphate of calcium, sulphate of arsenic, or sulphide of 
barium, made into a species of paste with hot water. This is applied 
over the surface with a spatula, and permitted to remain till it dries, 
a period usually requiring ten minutes. It is then rapidly removed 
by scraping with the spatula, and the surface thoroughly cleansed 
with warm water, after which it is anointed with cold cream, or other 
similar unguent. 

Of these depilatories Duhring recommeuds the following : 

R . Barii sulphis. 3ij ; 8 

Pulv. oxid. zinc. ) ._ ,_... 12 

Pulv. amyl. j aa dllJ ' • - M. 

The following are formula? devised by French authors. 
R. Sodii sulphat. Siij; 12 

Amyli pulv. j aa 3x ; 40 M 

To be finely triturated, and when used, to be made into a thin paste 
with water. (Boudet.) 

R. Calcis 3j; 4 

Sodii carbon. 5jss; 6 

Cerat. adipis gj ; 32 M. 

To be applied as a depilatory in the manner of a paste. 

All of these require caution in their use, and should never be 
intrusted to unprofessional hands. 

Shaving may be practised upon the hirsute face of women, and, 
with a similiar end in view, epilation also ; the latter, particularly in 
cases of hypertrophy of the hair, limited in extent. Partial suc- 
cess has attended the thrusting into the follicles of needles, pre- 
viously dipped in various caustic solutions, or heated in various 
degrees, but these methods are all far inferior to electrolytic destruc- 
tion of the hair-papilla. 



404 DISEASES OF THE SKIN. 

3. Of Connective Tissue. 
Sclerema Neonatorum. 

Gr. oK/>jpi}Q, hard ; vkov, lately; yewou, to bring forth. 

Sclerema Neonatorum is a disease of early infancy, induced by changes in 
the capillary circulation, accompanied by a progessive fall of temperature, 
and characterized by blanching, oedema, and even mummification of the 

skin. 

Symptoms. — The disease occurs, as a rule, iu from three to six days 
alter birth, and is characterized by a progressive cooling of the surface 
of the body, with an increasing- and extending- oedema, first most notice- 
able in the lower extremities. The skin is blanched, marbled, mottled, 
or more rarely of a yellowish, reddish, or violaceous hue, pits upon 
pressure, and later is indurated, firm, tense, and shining. The con- 
dition becomes more or less rapidly noticeable over the other parts of 
the body, the face, upper extremities, and trunk. As a consecpuence, 
motion is impeded, the features are stiffened, suction of the nipple is 
rendered difficult or impossible, and the infant reclines helpless, 
motionless, rigid, cold to the touch, and displaying the signs of a 
waning vitality merely by its moans and superficial respiration. 
Death usually occurs within a brief time. 

The respiratory and circulatory systems are in such cases always at 
fault. The disorder is common after capillary bronchitis, the pneu- 
monia of infants, and the gastro-intestinal disorders which prevail 
in premature, imperfectly nourished, and neglected infants of a tender 
age. 

Etiology. — The causes of the disease, whose cutaneous manifesta- 
tions seem to be largely symptomatic, are to be sought in every sys- 
temic disorder of early infancy which is accompanied by retardation 
of the respiration and circulation. For several years the author had 
the opportunity of studying the changes which precede a fatal issue in 
a large proportion of the abandoned and diseased foundlings cared 
for in the infirmary of the Chicago Home for the Friendless, and 
in several were distinguished unmistakable symptoms of sclerema 
neonatorum. Three of these waifs had been, significantly, abandoned 
at the door of the institution in very cold weather, and had there 
remained for several hours exposed and unnoticed. In none was it 
necessary to seek for causes any more profound than those which the 
history of each case suggested. 

Authors have, however, regarded the disease as produced by atelec- 
tasis pulmonum, cardiac disorders, and unknown constitutional con- 
ditions. 

Pathology. — Post-mortem, there is discovered no hypertrophy of 
the cutaneous elements. The tissues are simply distended with yel- 
lowish-white serum — in other words, are cedematous. This fluid, often 



SCLERODERMA. 405 

containing fat globules, flows forth after incision of the parts, more 
or less stained by the coloring matters of the blood, which was during 
life in a state of partial stasis. The stearine-like deposit found in the 
panniculus adiposus, is mere coagulated lymph, whose movement has 
been arrested and whose temperature has been lowered simultaneously 
with that of the blood. The subcutaneous tissue is usually so infil- 
trated that it is readily separable from the fascia? and aponeuroses 
beneath. The brain, lungs, kidneys, and serous membranes are often 
found coagulated and infiltrated with fluid. 

Diagnosis. — The disease is readily recognized by its characteristic 
features exhibited in very early infancy, and in subjects suffering 
from any cause which strongly depresses the respiratory and circul- 
atory activity. It is to be distinguished from sclerema adultorum, 
in which there is a hide-bound condition of the integument of very 
slow progress and rarely generalized. The latter disease is due to a 
true hypertrophy of the cutaneous elements. 

Treatment. — The treatment should be exclusively directed to the 
restoration of warmth, the stimulation of the respiratory and cir- 
culatory centres, and the proper alimentation of the little patient. 
Massage and cutaneous frictions, with artificial heat applied exter- 
nally, are serviceable. The prognosis is grave. Infants are said to 
have been saved after exhibiting these symptoms. The author has 
seen none such recover. In the discussion, however, of a case pre- 
sented by Dr. JRobinson to the New York Dermatological Society in 
1883, several cases of recovery were reported. 



Scleroderma. 

Gr. GKA?]p6£ ; hard; dspjia, the skin. 

Scleroderma is a chronic affection, characterized by a circumscribed or rela- 
tively diffuse induration, rigidity, fixation, and subsequent atrophy of the 
skin, the affected parts being yellowish-white, waxy, or pigmented in color, 
and either elevated or depressed, the disease-process enduring for a series 
of years, and, in certain cases, terminating fatally after the induction of 
marasmus. 

The disease, also termed Scleriasis and Sclerema, is manifested 
either as a partial or general change in the structure of the skin. 
The former, much more commonly encountered, is termed by French 
authors, solereme en placards. 

There can be little question to-day that niorphoea and scleroderma 
are different names for one and the same disease, though the two 
have been separately considered by many authors. In the following 
pages, adhering to the nomenclature of the American Dermatological 
Association, the conditions indicated by each name are for the present 
separately described, a temporary provision looking to more exact 
knowledge of the entire subject. Under the title, Morphoea, will be, 
therefore, found a description of the localized forms of scleroderma, 
to which that name has long been applied. 



406 DISEASES OF THE SKIN. 

Symptom*. — In both the partial and generalized forms, the disease 
is first manifested in irregularly defined roundish or ovalish, coin of 
palm-sized patches, in elevated or depressed, yellowish-white or waxy, 

ribbon-like bands, or in a more extensive and uniform involvement 
of the skin, usually that of some part of the upper segment of the 
body. The affected areas in both of the forms named maybe ele- 
vated slightly above the level of the adjacent normal integument, 
or to an equal extent depressed below it, or both, the depressions 
being irregularly distributed among the elevation-, or, especially in 
the ribbon-like form, bordered on either side by dense ridges. In all 
fully developed cases, the most prominent feature is the sclerosis, the 
skin being shining, indurated, brawny, tense, pigmented, and immov- 
able upon, because adherent to, its underlying structures, as the 
muscles, aponeuroses, and periosteum. 

For this reason, there is at times interference with the movements 
of the trunk in respiration, as also of the lips and other parts of the 
face in the expression of the emotions, and of the fingers in the 
grasp of the baud. The disease, in short, produces the condition 
often described as "hide-bound." The skin of the affected parts is 
usually yellowish-white, dirty, yellowish, waxy, or like alabaster in 
color; is often slightly desquamating, and may be pigmented iu various 
shades from yellow to brown and bronze. There is usually no 
alteration iu the subjective sensations, temperature, glandular secre- 
tion, uor, in the early stages of the disease, in the general health of 
the patient. The malady begins insidiously, but may, however, be 
rapid in its development, and accompanied by pyrexic or rheumatoid 
symptoms. Iu its subsequent progress, it always pursues a chronic 
course. 

There is no strict line of demarcation between the sclerosed and 
unaffected portions of the skin. The # temperature of the affected 
part may be at times slightly subnormal. 

After the complete evolution of the disease, when the sclerosed 
patch has attained a maximum of induration and thickening, the 
disease may disappear by resolution, or marked atrophy result. This 
atrophic process may involve both the skin and its underlying struc- 
tures. A dead-white, thinned, pinkish, slightly pigmented, or dirty- 
yellowish membrane may then be seen tightly stretched over a joint 
or a projecting osseous surface. 

The course, therefore, of the disease may be either toward definite 
resolution, persistent cutaneous atrophy, or the final induction of a 
fatal marasmus. But little is known of the concluding stage of the 
affection, patients, before arriving at that term, usually drifting from 
the observation of practitioners. Nearly twenty fatal cases are, 
however, on record. The skin may be entirely restored to its normal 
condition, but often such restoration is succeeded by a return of the 
disease in the part originally affected, and by the involvement of new 



The sites usually involved are: the head, trunk, and upper ex- 
tremities, including the mamma of women. It is occasionally of 



SCLEEODEEMA. 407 

symmetrical development. When occurring upon the face, an ex- 
ceedingly characteristic symptom is the resulting immobility of the 
features, head, thorax, digits, and even the limbs. 

Its lesions are accompanied at times by other cutaneous disorders, 
such as eczema, erysipelas, melanoderma, canities, anidrosis, morphoea, 
zoster, and acne. 

Exaggerated forms of the disease have been noted by several 
authors, where, to a varying extent, the surface of the lateral half 
of the face has been involved, the resulting condition being described 
as Hemiateophia Facialis. Here not only the subcutaneous tissue, 
but the aponeuroses, periosteum, and bones may participate in the 
atrophy, a fact well illustrated in the case of Robinson's patient, 1 
whom the author had the opportunity of examining. In this instance 
there was also a distinct sclerodermatous lesion on the face of one 
thigh. 

Scleroderma is exceedingly rare ; and the preceding description is 
based upon the notes of the few cases which have fallen under the 
author's observation. In one male patient, the surface of the entire 
chest was symmetrically involved to the extent of inducing marked 
dyspnoea, and the general condition was that of decided asthenia. 
His skin was tightly bound in undulating ridges to the ribs beneath, 
and colored in a dirty-yellowish shade. The other patients were 
much less seriously affected; one had symmetrical scleroderma of a 
part of the skin of the thorax in irregular patches ; another, a band- 
like deep yellow depression between dense ridges which fastened a 
part of the forehead firmly to the frontal bone ; the fourth, a limited 
whitish patch at the back of the neck ; and the fifth, a diffuse sclero- 
derma of the cutaneous envelope of the left mamma, the patient 
dying in a neighboring State one year after my examination of her 
person, of what her physician pronounced to be "sarcoma" of the lung. 

Finlayson 2 has observed in one case symmetrical gangrene of the 
extremities, a complication related without doubt to the " symmetrical 
asphyxia of the extremities" described by a number of English 
authors. The so-called "Glossy Fingers" and the "Sclerodactylia" 
of symmetrical distribution may belong to the same category. 

In many of the asymmetrical forms of the disease, and in others 
also, the sclerosed patches occur in the areas definitely supplied by 
certain nerves, or in the lines of nerve trunks. The lilac-tinted 
border, described more fully in connection with morphoea may dis- 
appear as the disease progresses. In exceedingly advanced stages 
the pigmentation may be deep and extensive. The complications of 
such stages are naturally associated with circulation disturbances ; 
and may be erysipelatous, gangrenous, or ulcerative. Amyloid 
degeneration of the viscera may also complicate any case. 

Etiology. — The causes of the disease are obscure. It is observed 
in about two-thirds of all cases in the female sex, a fact which 
certainly points to some other cause than rheumatism as effective in 

1 Amer. Jcrarn. of the Medical Sciences, Oct. 1878. 

2 Med. Chronicle, Jan 1886 



408 DISEASES OF THE SKIN. 

its production, since men arc more exposed than women to changes 
in atmospheric temperature and humidity, which agents are generally 
admitted to have an etiological importance in rheumatism. The 

disease occurs at all ages, chiefly, however, in adults. Cruse observed 
one ease in a child two years old. 

The etiological importance of the nervous system is, in the explana- 
tion of many cases, too obvious to require demonstration. This is 
much more distinct in the localized manifestations of the disorder 
where a region supplied by a single nerve or traversed by a nervous 
trunk is solely involved. Harley, Schwimmer, and others have 
recognized cardiac and gastric disturbances ; AVestphal and Eulen- 
berg, central and peripheral changes in the nervous system ; Heller 
demonstrated in one case a closure of the thoracic duct. Bancroft 1 
repeatedly recognized filarise in large numbers in the blood of a 
young girl in Australia affected with a characteristic scleroderma. 

The disease is regarded to-day by the greater number of observers 
as a trophoneurosis. 

Pathology. — The confusion which has existed in relatiou to the 
question of the identity of scleroderma and morphcea is due to various 
causes. By several authors similar symptoms are described under 
each of the two names : and the symptoms described as peculiar to 
each are occasionally seen either simultaneously or successively in 
the same individual. 

Microscopical examination of the tissues involved in the disease 
has proved unsatisfactory. The connective tissue of the skin has 
been fouud, according to Kaposi, condensed and thickened ; its 
elastic fibres multiplied at the expense of the panniculus adiposus ; 
its muscular tissue hypertrophied ; the pigment in the rete and 
corium increased ; the sweat glands dilated ; the lumen of the blood- 
vessels diminished, and their walls ensheathed in accumulations of 
what he terms " lymphatic cells." 

Schwimmer and Bates found vascular changes including a narrow- 
ing of the vessels, thickening of the tunica media and intima. In 
the atrophic sequel* of the disease the new elements disappear. 

Diagnosis. — A differential diagnosis between scleroderma and 
morphcea involves, as has been already shown, chiefly a distinction 
between the partial and general manifestations of the disease. 

Scleroderma is occasionally symmetrical, usually insidiously 
developed, void of subjective sensations, and indeterminate in out- 
line. Morphcea is usually asymmetrical, often accompanied by 
pain or tingling, and exhibits a particularly well-defined contour. 
Scleroderma may affect large areas of the integument which are at 
some time densely rigid and firm, and may not exhibit to the eye a 
structural change. Morphcea is of much less extensive development, 
produces a soft, somewhat elastic or " cushiony " feel to the touch, 
and alters the skin so that the eye can take cognizance of the change. 
The former commences as a cutaneous sclerosis ; the latter as a patch 
of altered color, the change of hue being due to a greater or less 

1 Lancet, Feb. 28, I8SG, p. 380. 



MORPHffiA. 409 

degree of vascularity. Lastly, in scleroderma there is no telangiec- 
tasis, nor punctate atrophy. 

Treatment. — The treatment of scleroderma, though empirical, should 
be persistently enforced in the hope of improvement. Locally, baths 
(cold, hot, sea, vapor, Russian), massage, frictions with fat and oils, 
and possibly the hypodermatic injection of pilocarpine (Besnier, 
Doyon) may be advantageously tried. The inunction of mercurial 
and iodized unguents has proved futile. Internally, quinine, iron, 
arsenic, cod-liver oil, and the usual hygienic and tonic regimen, are 
in different cases severally indicated. 

In some cases the galvanic current has been employed with marked 
benefit, applied locally to the patches of disease, and in the direction 
of the trunks of nervous supply, and over the nervous centres. 
Rasmussen applies locally an ointment of the black oxide of copper, 
two grains (0.133) to the ounce (32.). 

Prognosis. — The outlook for the patient affected with extensive 
scleroderma, especially of the trunk, is decidedly unfavorable. Much 
more limited expressions of the disease may be regarded as less grave. 
Recovery in cases is said to have been perfect. Atrophy once estab- 
lished, is final. Contracture of mouth, fingers, or costal region may 
prove serious. Patients yielding to marasmus are naturally those to 
whom little can be promised. Even after slight manifestations of 
the disease, the future may be portentous. 

Morphcea. 

Gr. fiopcpfj, by metathesis, form. 

Morphcea is a cutaneous disease characterized by the occurrence of one or 
several discrete, well defined, firm, and smooth points, patches, lines, or 
bauds, often slightly elevated or depressed, and surrounded by a delicate 
violaceous or lilac-tinted halo, whose involution may be followed by 
macular, punctate, or striate atrophy of the skin. 

Symptoms. — This disease, once known under the misleading title 
of "Addison's Keloid," is to-clay best regarded as a local manifesta- 
tion of scleroderma. The following is a brief description of the 
most typical form of the disease observed by the author : 

The patient was a vigorous, well-nourished girl, sixteen years old, 
with a patch upon the outer face of the left thigh, as large as a 
breakfast plate and almost as perfectly circular. It was slightly 
elevated in its centre above the adjacent level, and thence declined to 
the periphery by a gentle curve quite perceptible when viewed from 
the side. It was firm but not indurated, feeling to the finger like a 
densely padded cushion set in the skin. With some difficulty it 
could be gathered up between the fingers. Sensibility was slightly 
impaired over its surface. Its outline was so distinct that its limits 
could have been traced by a pen. The surface was exceedingly 
smooth, and colored in a shade between alabaster and yellowish wax. 
Regularly dispersed over the surface of this circular cushion, were 



410 DISEASES OF THE SKIN. 

discrete, slightly pigmented, atrophic puncta, separated from each 
other by an inch or less of the shining substance constituting the 
patch. About it was a delicate, elegant, and very regularly dis- 
played halo of a violaceous tint, which on close inspection could be 
.-ecu to be produced by a plexus of minute capillaries. 

Of the few cases of this rare disease which the author has had the 
fortune to see, no one was comparable with that described above, as 
respects the size of the patch, and the classical type of the features. 
In another case, observed lately in private practice, a female child 
exhibited a small hen's egg-sized patch on the left temple, the in- 
volved part projecting to a marked extent above the level of the sur- 
rounding skin. The same violaceous halo surrounded the part, made 
up, as was evident on close examination, of a delicate vascular plexus. 

Other forms in which the disease is manifested are one or more 
coin- to palm-sized patches approximately circular, either at the 
general level of the integument or slightly depressed below it, in 
which the tissues are either natural, or unusually firm, tense, and sug- 
gestive of a tightly stuffed cushion. The surface may be rosy pink, 
whitish, yellowish, lardaceous, purplish, mottled, or pigmented. It 
may resemble marble, alabaster, wax, bacon, or a piece of tanned 
leather. Occasionally there is superficial desquamation. Often minute 
bloodvessels ramify over its surface, or in the areola, beyond which 
also the skin may be pigmented in various shades. The centre is 
often partly anaesthetic. After existing for months and even years, 
these lesions may undergo involution, leaving an unaltered integu- 
ment where once they existed, or, more commonly, a contracting 
cicatriform atrophy of the skin and often also of the subcutaneous 
tissues, the resulting scar becoming agglutinated to the structures lying 
beneath it. 

The lesions may often also be first observed as punctate or striate 
atrophic depressions. An exaggerated form of the latter is the more 
or less broad, grooved streak, or furrow, in the sunken floor of which 
is a glazed, white, firmly attached, and insensitive epidermis, bounded 
on either side by hypersemic, pigmented, or otherwise altered, smooth 
edges or ridges. Whether, however, in the form of patches, puncta, 
stride, furrows, or broad grooves, these changes must in many cases 
be sequela? of the insidious deposition of lardaceous material to a 
corresponding extent, whose resorption has been unnoticed. As in 
the case of stria? et macula? atrophica?, many of these lesions are 
mingled with, or surrounded by, variously colored, pigmented, hyper- 
a?mic or telangiectasia patches, streaks, lines, or mere shadows. 
Often a delicate, yellowish, or violaceous streak cau be distinguished 
in the immediate proximity of these curious lesions, and the most 
careful scrutiny will fail to define either its outline or character. 

The disease occurs asymmetrically, and often unilaterally, upon the 
face, back of the neck, surface of the trunk, including the breast of 
women, the belly, the arms, and the thighs. It is said, also, at times 
to select the areas supplied by certain nerves, a feature by no means 
distinctive of the disease. Tilbury Fox, for example, writes that 



MORPHEA. 411 

" when morphoea occurs on the forehead, it takes the course of the 
supraorbital nerve ; " but I have certainly seen one perfect frontal 
groove, with pigmented, yellowish edges, terminating fully an inch 
from the supraorbital notch. 

Etiology. — The causes of the disease are unknown. It rarely 
occurs in men, a large proportion of all patients being women. I 
have, however, seen an oval patch two inches in length upon the back 
of the neck of a young man. All my patients, one child only ex- 
cepted, were individuals in early adult life, though it is said to occur 
at all ages. The subjects of the disease are both vigorous and weakly. 

Pathology. — The studies thus far made of the^ microscopical 
anatomy of the disease have neither sufficed to demonstrate its iden- 
tity as distinguished from scleroderma, nor to explain satisfactorily 
the polymorphism of the affection. Duhring, in one case, established 
shrinkage of the upper and condensation of the lower layers of the 
corium ; while Crocker, 1 beside noting the usual phenomena of mul- 
tiplication of the elements of the derma and secondary changes in the 
rete and skin glands, thought there was also a fibrous metamorphosis 
of the protoplasm, lending color thus to the view of Fox, that the 
disease is essentially a fibroid degeneration of the skin. 

The neurotic explanation of the disease, suggested by Hutchinson 
and others, may be said to have generally commended itself to late 
observers. Morphoea, in fact, is a localized scleroderma, and its 
position will probably be one day fully established among the tropho- 
neuroses of the skin. 

Diagnosis. — For the distinctive differences between morphoea and 
scleroderma, when such are recognizable, the reader is referred to the 
details presented in connection with the diagnosis of the last-named 
disease. From the patches of vitiligo those of morphoea are readily 
distinguished by the entire absence of all structural cutaneous changes 
in the former, aud their characteristic milky-white color, the hairs of 
the part being also blanched. Both the pigmented macules and 
atrophic patches of lepra are remarkable for their anaesthetic condi- 
tion, and their coincidence with, or sequence from, other readily 
recognized symptoms of the disease, such as tubercles, bullae, ulcers, 
and involvement of the hairs, nails, eyes, and other organs. 

Treatment. — In many of the milder cases of morphoea, especially 
those existing upon portions of the surface concealed by the clothing, 
there is no indication for treatment. The patient's general health is 
unimpaired, and the local disorder unproductive of either present 
discomfort or a menace for the future. When the disorder is facial, 
and atrophy has already occurred, the resulting disfigurement may be 
regarded as remediless. For the earlier stages of the disease upon 
the face, and for those lesions in other situations which, from their 
size, number, or progress, are portentous, general and local treatment 
may be required. The former includes the use of iron, quinine, 
arsenic, cod-liver oil, strychnia, and phosphorus, with the usual 

1 Lancet. November 22, 1S70. 



412 DISEASES OF THE SKIN. 

roborant regimen and diet. The latter involves the application of 
the various simple stimulants, frictions with oil, spirits, and soaps, 
singly <»r in combination ; lotions with the mercuric bichloride, mas- 
sage, and the employment of the galvanic current. In pregnant 
women treatment should he deferred till after delivery, when involu- 
tion may be more speedily obtained. Young girls, chlorotic, anaemic, 
and suffering from .menstrual derangements, should be taken from 
the school -desk and the piano-stool, and sent to the riding-gallery, 
the gymnasium, or the dairy-farm, where they can swallow a goblet 
full of pure, fresh milk after each meal. 

Prognosis. — The disease may terminate by spontaneous and perfect 
restoration of the part. Adherent atrophic stria? or patches are 
remediless. The progress of the disease is exceedingly indolent, and 
may continue for a lifetime. Occasionally grave sequela? may be 
anticipated. 

Elephantiasis. 

Gr. el£$ag, elephant. 

Elephantiasis is a chronic disease of the cutaneous and subcutaneous tissues, 
usually limited to certain regions of the body, preceded by the occurrence 
of some inflammatory process in the blood- and lymphatic vessels of the 
affected part, and resulting in an enormous increase in its volume, with 
hypertrophy of the structures of which it is composed. 

Symptoms. — This disease, long known as Elephantiasis Arabum, 
Pachydermia, Bucnemia Tropica, and Elephant Leg, or Barbadoes 
Leg, is encountered more frequently in and near the tropics, but 
sporadic cases occur in all countries. Perfectly typical instances of 
the malady have been noted in almost every part of the United 
States. 

Fig. 49. 




Elephantiasis of the foot and leg. 



Its most frequent seat is the lower extremity of one side, where it 
involves the foot and leg, though the thigh of the same limb may 



ELEPHANTIASIS. 413 

also enlarge. The penis and scrotum of the male, the labia and 
clitoris of the female, the upper extremities, the face, and portions of 
the trunk may likewise become involved. 

The disease is insidious in its approach, and remarkably chronic in 
its career. Usually, localized inflammations precede, as an erysipelas 
or a dermatitis, with or without some involvement of the lymphatic 
vessels and glands. At the same time there is a condition of general 
fever. To this succeeds a defervescence, with abatement of the local 
inflammation ; its sequelae becoming manifested in a more or less 
persistent oedema of the part lately inflamed. After intervals of 
days, weeks, or months, the pyrexia recurs with still greater involve- 
ment of the swollen tissues which, with each access of fever, increase 
in volume and gain in density. When the elephantiasic condition is 
fully developed, the skin is found to be tense, glossy, and blanched 
or discolored in various shades. Pressure upon the oedematous part 
is followed by pitting, but the tissue beneath is felt to be brawny and 
indurated. The parts beneath the skin are perceptibly increased in 
volume, especially the subcutaneous tissue ; and the circumference of 
a limb thus diseased may be several times larger than that of its 
fellow. A lymphangitis is usuallly declared by painful, cordlike, 
linear indurations of the part, associated with adenopathy of the 

Fro. 50. 




Elephantiasis scroti. 



nearest ganglia. In older cases, the skin loses its glabrous aspect, 
and exhibits eczematous, verrucous, papillomatous, seborrhoeic, and 
even ichthyotic changes. Pigmentation, even to a blackish tint, may 
ensue; scaling, Assuring, and furrowing are common; and the accum- 
ulation of altered sweat and sebum in these depresssions is the 



414 DISEASES OF THE SKIN. 

source of an offensive stench. During the course of the disease 
almost all of the elementary lesious of the skin may be displayed by 
the skin, maculae, vesicles, papules, tubercles, pustules, blebs, ulcers, 
crusts, scales, excoriations, and fissures. Warty growths form as 
large as those seen in ichthyosis hystrix, and in some cases reddish- 
colored tumors spring from the hypertrophied integument. 

When fully developed in the lower extremity, the unwieldy limb 
with the foot, ankle, and leg massed into one huge, cumbrous 
cylinder, bears a striking resemblance to that of the elephant, from 
which circumstance the malady first received its name among the 
Arabs. Locomotion is then greatly impeded, or rendered impossible. 
No less striking is the similar deformity induced in the female labia 
or male scrotum, the latter at times hanging far below the knees. 
In its rugous folds the penis disappears, and the urine is passed 
along a gutter formed of skin transformed into quasi-mucous mem- 
brane. As a consequence of the fissures and excoriations which 
form, the lymphatic channels are finally opened, and a true lymphor- 
rhoea results. After similar processes the ear may become largely 
pendulous by the side of the neck. 

Subjectively, the disease may be regarded as productive of less 
discomfort than would be suggested by its formidable features. Pain 
is occasionally experienced, and, during the exacerbations accompa- 
nied by pyrexia, there is corresponding malaise. The chief subjective 
sensations are those induced by the weight and consequent tension, 
inseparable from the enormous masses of hypertrophied tissue. 

Etiology. — The causes of elephantiasis are exceedingly obscure. 
Predisposition of races or individuals, heredity, climatic influences, 
malaria, fatiguing labor with the feet and legs immersed in water, 
aud filth in connection with "misery," have all been cited as favor- 
ing conditions. To these should be added the local disorders 
especially common in the lower extremities, which have in cases 
proved to be the points of departure of the elephautiasic hypertrophy, 
such as obstruction to the blood or lymphatic currents by pressure 
of tumors, pregnancy, or neoplasms ; ulcers, cicatrices, and the 
presence in the blood of the filaria sanguinis hominis. 

Lewis and others have demonstrated the presence of embryos aud 
filaria, adhering to the walls of both lymphatic and bloodvessels in 
elephantiasis of the tropics ; but the occurrence of the malady where 
such parasites do not exist is to be explained on other grounds. 
The. disease is especially prevalent in the East and West Iudies, 
Egypt, Arabia, Abyssinia, Africa, Malabar, Barbadoes, Brazil, 
Mexico, aud parts of China. 

Pathology. — Even macroscopically, the elephautiasic mass is seen 
to be built up of hypertrophic elements representing all the tissues 
of which the part is composed. The knife with difficulty divides 
the homogeneous, whitish, and lardaceous mass, from which on 
pressure exudes a fluid of similar color. The subcutaneous connec- 
tive tissue is found relatively much more enlarged and sclerosed than 
the epidermis and derma ; though when the section is made through 



ELEPHANTIASIS. 415 

the rugous aud warty skiu described above, all the elements of the 
papillary layer, rete, and stratum corneum are seen to participate in 
the changes described in connection with the pathology of verruca. 
Here and there are loculi filled with a fluid lymph. The sheaths of 
the bloodvessels, lymphatics, and nerves, the bones, muscles, and 
aponeuroses are also thickened, solidified, and occasionally aggluti- 
nated, so as to be almost indistinguishable in the mass of uniformly 
sclerosed tissue. The pigmentation of the derma is marked : the 
nuclei of the connective-tissue cells are multiplied ; and the cutaneous 
glands intact, hypertrophied in their epithelial linings and invest- 
ments, or, at a later stage, atrophied. 

It is evident that in many cases, as Virchow has pointed out, the 
earliest of the changes to be noted occur in the lymphatic glands and 
vessels, the whitish and yellowish lymphatic fluid which then accu- 
mulates in the tissue, resulting from obstruction of some of the lymph 
channels. In some of the remarkable cases on record the lymphatic 
obstruction is the prominent feature of the disease ; and the elephanti- 
asic enlargement subordinate in gravity to the former condition. 
Such are, for example, the noteworthy instances in which the lymph 
distends multiple cutaneous vesicles, after rupture of one or more of 
which that fluid streams away to a dangerous extent. For a fuller 
description of this interesting class of cases, the reader is referred to 
Busey's careful monographs on Occlusion and Dilatation of the 
Lymph Channels. 

Diagnosis. — The striking deformity, which characterizes elephanti- 
asis, will always suffice for its recognition. In the earliest stages of 
the disease, when merely an erysipelatous or eczematous condition of 
the skin can be determined, it would be difficult, if not impossible, 
to decide as to the future of the disorder, especially in a locality 
where only sporadic cases occur. A symmetrical hypertrophy of 
both legs and both feet developing in this country, even though 
described as " elephantiasis," should be most carefully studied before 
a diagnosis is made of the particular disease here considered. The 
same might even be said of elephantiasis of but one inferior extremity. 
The author was once requested to examine a patient with extensive 
deforming induration and enlargement of the right leg and foot, ac- 
companied by pigmentation and a well-marked warty condition of the 
skin, who had been pronounced the victim of idiopathic elephantiasis 
Arabum. It was discovered that the patient had had a fracture of 
the upper third of both bones of the same leg during the previous 
year, and had since constantly worn a tight bandage, encircling the 
limb at the seat of the injury. The deformity rapidly disappeared 
under the application of a roller bandage extending from the toes 
upward. 

A peculiar and rare, though characteristic, deformity of the labia 
majora of women — most commonly the labium majus of one side — 
results from a tertiary, syphilitic, gummatous infiltration which must 
be distinguished from elephantiasis. In such cases the history of the 
disease and the relative inferiority as to bulk of the affected organ, 



416 DISEASES OF THE SKIN. 

points to the nature of the disease. The syphilitic labium rarely 
exceed- the size of a large fist. 

Treatment. — In the early -tap's of elephantiasis, the febrile condi- 
tion of the patient and the localized cutaneous inflammations, are to 
be treated by the measures appropriate for the relief of these condi- 
tions. Quinine, especially in malarial districts, is of the highest 
importance. When the elephantiasic development is established, if 
the genitals are involved, the knife of the surgeon offers the best 
prospects. The result of such interference, both in the genitalia and 
extremities, has been in many cases brilliant indeed, though the 
mortality of such severe operations is necessarily great. When the 
lower extremity is involved, it should be maintained in a horizontal 
position, it- ulcer- if possible healed, its excresceuces removed, its 
circumscribed inflammations resolved, aud then elastic compression 
be carefully and skilfully maintained by means of the rubber bandage. 
The toes are first separately enveloped; then the foot and ankle; 
and lastly the leg. The results are sometimes highly satisfactory. 

Ligation and digital compression of the main artery supplying the 
elephantiasic leg, have been occasionally followed by transient 
improvement. Instrumental compression has at times resulted in 
severe ulceration, and a reawakening of the erysipelatous affection. 
Multiple punctures and incisions, made with a view to giving exit 
to the fluids contained in the mass, have been attended by no greater 
success. The main obstacle in all these surgical procedures, is the 
lymphangitis which so frequently complicates the situation. None 
of them promises so well as nerve stretching, which, in a few isolated 
cases, has been followed by noteworthy results. Excision also of a 
portion of the sciatic nerve has been followed by satisfactory changes. 
The use of the galvanic current has, when long continued, accom- 
plished resolution of engorged masses of tissue. Elastic compression 
in the horizontal position for all cases not warranting nerve stretch- 
ing, may be regarded as the wisest course when the extremity is 
involved. For the local treatment of the pachydermia proper, green 
soap, mercurial ointment, and bathing in hot or cold lotions, may be 
advantageously employed. For patients whose disease is acquired 
in countries where the deformity is prevalent, a change of climate is 
of the highest importance; and, having in view the social surround- 
ings and habits of most victims of the disease, it is scarcely necessary 
to call attention to the need of a proper hygiene, diet, and tonic 
regimen. 

Prognosis. — The future of a patient affected with the disease may 
be regarded as most favorable when the latter exhibits an early 
tendency to respond favorably to appropriate treatment, and when 
circumstances permit of a resort to the best therapeutic measures 
which can be adopted, such as change of residence, persistent and 
careful dressing of the affected part, and the removal of any exciting 
cause of the disease, such as a neoplasm, indurated cicatrix, etc. In 
the severer cases, a fatal result may be precipitated ; but usually life 
is prolonged, burdened by the inconvenience of the enormous 



ROSACEA. • 417 

elephantiasic mass in comparison with which the rest of the body 
ofteu seems to serve as a mere appendage. 

Lymph Scrotum, Varix Lymphaticus, or Nsevoid Elephantiasis, 
fully described by Wong, Carter, Fayrer, Manson, and other East 
Indian observers, is that condition in which the inguinal and femoral 
glands become large and soft, and the scrotum covered with vesicles 
and distended with dilated lymphatic vessels all filled with coagu- 
lable lymph. As in elephantiasis of other organs, there may be 
preceding fever, chills, erysipelas, and other localized inflammations. 
The disease is produced solely by the filaria sanguinis hominis, and 
may be associated often with chyluria on the one hand, and elephan- 
tiasis of other organs on the other. 



Rosacea. 

Lat. rosa, rose. 

Rosacea is a chronic cutaneous disorder, chiefly of the face, characterized by 
irregularly disposed, rosy or reddish maculations often produced by telan- 
giectasis of the skin capillaries, or forming split-pea sized and larger 
hypertrophic nodules most commonly seated upon or about the nose. 

The condition of telangiectasis described under this title, is almost 
identical as regards its clinical features with acne rosacea (Gutta 
Rosea, Copper-nose), to which the reader is referred. In what fol- 
lows, it is attempted to portray the affections of this class which 
may be properly described as hypertrophic in character ; relegating 
the acneiform cases to the chapter devoted to Acne Rosacea. 

[A.] Erythematosa. 

Symptoms. — The eruption is usually displayed in middle life or 
later, and chiefly upon the face of both sexes. In these, the nose 
(tip, alse, root), brow (especially near the root of the nose), chin, 
cheeks, temples, or lips, may be the seat of reddish or rosy blotches. 
The effect is a marked unsightliness for which chiefly or only the 
advice of the physician is sought. These maculations are usually 
unproductive of subjective sensations, or of objective feeling of heat. 
They may be so numerous as to implicate all the regions named above 
to a great degree, or be limited to one or two adjacent regions, or, 
lastly, be spread very profusely over the entire face in minute blem- 
ishes not more developed at one point than another. 

The very greatest irregularity may be noted as to their contour, 
the spots being pin-point to nail-sized, roundish, radiating, stellate, 
linear, tortuous, or in any fantastic outline. The colors vary from a 
delicate rosy pink to a deep purplish crimson. Viewed with care all 
are seen to be produced by a double process of dilatation, and new 
formation of the skin capillaries. 

This condition is subject to marked aggravation, or at least tran- 



418 DISEASES OF THE SKIN. 

sient change of features after the operation of any cause tending to 
congest the vessels of the head, such as dietetic stimulation, coughing, 
laughing, sneezing, active exertion, the application of hot water to 
the surface, exposure to the sun, etc. Alter such occurrence, the 
blood will visibly distend the vessels of the face, the color deepen 
and spread, and all features of the disorder become decidedly con- 
spicuous. Often a coexisting acne, or seborrhea faciei participates 
in these changes. The disease is seen with almost equal frequency 
in both sexes, but women rarely exhibit the succeeding stage of the 
disorder next described. 

[B.] Hypertrophica. 

After a longer or shorter continuance of the condition described 
above, a new formation of connective tissue with cell infiltration 
proceeds pari passu with the telangiectasis. In this way small or 
large pin-head to egg-sized tumors are developed, more particularly 
about the tip or aire of the nose, reddish or purplish in color, till the 
stage is reached which is elsewhere described as rhinophyma. The 
absence of inflammation is in these cases marked. The nose is often 
cold to the touch when bright red in hue, and may be of a pecu- 
liarly oily or greasy appearance in consequence of a seborrhoea oleosa 
of the part. The so-called "brandy-drinker's," "wine-drinker's," 
and "whiskey-drinker's," noses are of this class. 

Etiology. — The disease in its milder manifestations is common 
to both sexes, the hypertrophic forms being rarer and practically 
limited to the male sex. The causes of the disorder are numerous, 
but always operate by producing at first active or passive distention 
of the bloodvessels of the upper portion of the body. Among these 
effective causes may be named gastric dyspepsia (especially though 
not exclusively associated with intemperate use of alcoholic stimu- 
lants, including brandy, whiskey, wine, and beer); articles of clothing, 
surgical apparatus, tumors, etc., compressing the larger vessels at the 
root of the neck; the long-continued action of heat and cold upon 
the face, as also the local effect of chemicals, and the influence of 
certain trades and occupations of life tending to produce congestion 
of the face, as, e. g., among cooks, cab-drivers, swimming teachers, 
etc. In some cases there is a distinctly inherited tendency to dis- 
tention of the capillaries of the skin of the face; in yet others, the 
rosaceous blemish is congenital. Disease of the uterus and other 
viscera may be the remote sources of the trouble. 

Pathology.— The hypersemia usually begins as a transitory phe- 
nomenon in the more deeply seated plexus of vessels and, after per- 
manent distention has resulted, the vascular elements of* the more 
superficial strata of the corium, and those surrounding the sebaceous 
glands and hair-follicles become involved. In the hypertrophic 
lesions, there are new formation of connective tissue, enlargement of 
all portions of the corium, hyperemia and telangiectasis of the ves- 
sels, and dilatation of the sebaceous glands. 



FRAMBCESIA. 419 

Diagnosis. — Acne rosacea is to be distinguished from uncompli- 
cated rosacea by its characteristic lesions, comedones, papules, pus- 
tules, crusts, etc. In uncomplicated rosacea, there is only a macular 
lesion due to hyperemia or telangiectasis. The two disorders, thus 
artificially distinguished, are often found the one complicating the 
other, an acne being the origin of the hyperemia, which is the first 
rosaceous stage. The hypertrophic lesions of rosacea are also often 
thus associated with acneiform symptoms. Lupus, carcinoma, and 
syphilis of the regions affected by rosacea are commonly productive 
of ulcerative or destructive consequences which point to the nature 
of those affections. 

Treatment. — The treatment of rosacea is practically the same as 
that of acne rosacea, to the chapter devoted to which the reader is 
referred. The vessels producing the rosaceous blemish are to be 
destroyed, preferably by electrolysis; but the result may also be 
accomplished less elegantly and perfectly by incisions, followed by 
cauterization ; by curetting, by the Paquelin knife, by Brun's sharp 
spoon, Vidai's lancet, or B. Squire's multiple scarificator, the last- 
named instrument being only available for the larger lesions. The 
hypertrophic forms of rosacea are best remedied by the plastic opera- 
tions of modern surgery. 

Prognosis. — The lesions of rosacea, limited in extent, even though 
quite numerous, may be elegantly and permanently removed by 
electrolytic methods. The scars left after operations upon the larger 
lesions are usually superficial, and not disfiguring. The prognosis, 
after ablation of the largest hypertrophic lesions, is proportioned to 
the resources of surgery. In no case does general disease result. 

Framboesia. 

Fr. framboise, raspberry. 

Framboesia is a disease of the African race chiefly, manifested in pin-point to 
egg-sized and larger papulo-tubercular lesions, appearing mostly on the 
face, resulting in discharges and crusts, and in cases followed by systemic 
symptoms. 

This disorder, termed by Charlouis, Polypapilloma Tropica, is 
encountered chiefly among the negroes residing along the African 
coasts, in the West Indies, and in South America, where it is also 
known as Yaws and Pian. By Alibert it was termed Mycosis 
Frambcesioides. The contributions to the literature of this sub- 
ject have been made chiefly by Drs. Milroy, Nicholls, and Imray, of 
Dominica, and Dr. Bowerbank, of Jamaica. The malady is .said to 
be characterized at first by the occurrence of brownish-red, pin-head 
to pea-sized, flat maculo-papules. In these, one or more yellowish 
or whitish puncta become visible, which gradually develop into 
roundish papules or tubercles, resembling pea-sized and larger pus- 
tules of yellowish-red color. When the integument which covers 



420 DISEASES OF THE SKIN. 

these gives way, a fetid, sero-purulent fluid exudes, aud a dirty- 
yellowish, Bpongy mass projects from the reut, aud enlarges subse- 
quently, till it appears as a yellowish-red, crusted vegetation, an inch 
or more in diameter. This may degenerate into an offensive ulcer, 
whose destructive processes are accompanied by progressive emacia- 
tion and systemic disturbance. Instead of this retrogressive meta- 
morphosis, the tubercle may shrivel iuto a dark-colored, crusted, aud 
withered excrescence, yielding a fetid and ichorous discharge. The 
eruption occurs upon the face, neck, extremities, auo-genital region, 
and, rarely, upon the trunk. 

The lesions are seldom the seat of subjective sensation. They 
have been considered contagious, and not susceptible of transmission 
by heredity. The course of the disease usually extends through 
from two to four months. It is also said to occur at all ages and in 
both sexes, one attack conferring immunity against another. 

The constitutional symptoms of the malady include fever, osteo- 
copic pains, gastro-intestinal distress, arthritic troubles with ulcera- 
tions about the joints resulting in deformity, and eventually cachexia. 
The disease is both inoculable and auto-inoculable. Iuoculatiou 
results in the formation of a crust-covered ulcer, followed in from 
seven to fifteen days by a general eruption. The result is rarely 
fatal, the disease being concluded in most cases after a period of from 
three to four months duration. 

Most of the authorities who have personally studied the disease as 
it occurs in the African race, believe that frambcesia is a disease sui 
(/corn's. Certain it is that in both syphilitic aud non-syphilitic sub- 
jects, who have never visited the countries where it is claimed that the 
disease is endemic, similar symptoms have been recognized and 
described. An interesting case of framboesioid lesions in a syphilitic 
woman is reported by I)e Amicis; 1 and the author has personally 
treated three patients whose lesions corresponded very closely to those 
described above, no one of whom was syphilitic. It can be readily 
understood that a vegetation occurring upon the filthy skin of an 
unwashed negro in the tropics, might assume features which would 
be scarcely recoguized as classical, in the clientele of most practitioners 
in this country. 

It is safest at present to regard the term frambcesia as largely 
descriptive in scope, and as including certain papillomatous and other 
vegetations projecting from the surface of the body as a result of filth, 
syphilis, tropical temperatures, and possibly of other uufavorable 
agencies operating upon the skin of a negro. A sufficient commen- 
tary upon these considerations is afforded by the admission of the 
West India surgeons, that mercury aud the iodide of potassium are 
regarded as specifics for the disease as it exists in those islands, aud 
that cleanliness is of prime importance. 

1 Cf. a translation of his paper by the author in the Archives of Derm., October, 1879, p. 39. 



FRAMBQESIA. 421 



Parangi. 

Kynsey has presented a report upon the nature of the disease 
which is thus designated in Ceylon, where it prevails. It appears 
to present mixed features of syphilis, land scurvy, yaws, pellagra, 
lupus, leprosy, scrofula, and less severe disorders, existing as an 
endemic in certain provinces of the island. It is clear, from the 
description of the symptoms recorded, that the nature of the disease 
has not yet been recognized. It was first described by Loos in 
1868, and is now regarded as due to numerous causes, such as mal- 
nutrition induced by impure food and water, wretched hygienic sur- 
roundings, and infection from the discharges from ulcers. 

There is, according to Christie, 1 an incubation period of from two 
to eight weeks, followed by the appearance of an ulcer over any 
bony prominence — the initial sore. This is followed by malaise and 
pyrexia, the premonitory fever lasting from two to eight days, and 
followed by the exanthem which appears first over the face, and later 
on the body. This eruption may be vesicular, pustular, pustulo- 
tubercular, or squamous, superficial ulcerations forming which become 
subsequently crusted. JRupioid, furuncular, and psoriasiform features 
are common in the course of the malady. Condylomata may appear 
at the anus. Ulcerations succeed later of a more formidable char- 
acter, involving the nose, palate, and cheeks ; the digits may be lost 
by gangrene; blebs occur; pricking pains are experienced; there may 
be anaesthesia of some part of the surface, associated with bronzing 
and glazing of the skin. The patient may perish of some inter- 
current disorder or from exhaustion. 

The duration of the disease is said to be from two to eight years. 
Treatment has been successful with the cautious employment of mer- 
cury and the iodide of potassium, and strict observance of the rules 
of hygiene. 

Donda Ndugu ("brother ulcer," or "ulcer that clings") is a 
disease existing in Central and Eastern Africa. Dr. James Christie, 2 
who first described it, believes it to be identical with that from which 
Livingston suffered in 1870. 

The disease is confined to the lower extremities, and occurs among 
the natives chiefly in the rainy season after a march toward the 
coast. 

It is characterized by the appearance of whitish papules springing 
from a boggy swelling, seen often near the toes, heel, or dorsum of 
the foot. When incised, an extensive, deep-seated slough is found 
beneath the healthy tissue, bathed in an ichorous discharge. Severe 
rapidly -spreading ulcerations and death may ensue. Livingston ex- 
tracted the ova of a species of maggot from such lesions in his own 
person; but Christie failed to discover them in his cases. The treat- 
ment is local, by the use of antiseptics after incision. 

1 See Anderson's Treatise on Diseases of the Skin. 2 Loc. cit. 



422 DISEASES OF THE SKIN. 

CLASS V. 

ATROPHIES. 

1. Of Pigment. 

Absence of the pigment of the skin, giving rise to conspicuous 
disfigurement, is naturally most frequently encountered in those 
races of mankind whose skins are most abundantly provided with 
such pigment. The absence of pigment may be congenital or ac- 
quired, and partial or universal. Some confusion has been produced 
by the arbitrary distinction established by authors between the names 
intended to designate these several varieties of achromatia or leuco- 
pathia. In the following pages, leukoderma is the name employed 
to designate the pigment atrophy which is partial and congenital ; 
albinismus, that which is universal and congenital ; vitiligo, that 
which is acquired. 

Leucoderma. 

Gr. Ievko-, white ; depua, skin. 

Leucoderma is a partial congenital absence of pigment in the skin, most 
commonly observed in the colored races, and characterized by whitish 
patches or bands having an irregular border, the evidences of disease in 
such parts being limited to the changes in hue of the skin and hairs. 

Symptoms. — In these cases, the patients being most often of the 
colored races, one or several whitish or rosy-whitish patches or 
bands, varying as to size, outline, or situation, may be seen at birth 
unprovided with pigment. These may have a symmetrical arrange- 
ment, in which case they commonly observe the areas of distribution 
of one or more cerebral or spinal nerves, or be asymmetrical in dis- 
tribution. They are usually of circular outline, and may be fouud 
upon the scalp, face, nipples, breast, and genital region. The hairs 
found upon such parts are equally destitute of normal color, being 
usually white. Negroes thus marked are generally termed "pie- 
bald," and the integument similarly affected in persons of other 
races has long been recognized as the "pied" or "piebald skin." 
These blemishes, when symmetrical, like pigmentary naevi, exhibit a 
striking analogy with the symmetrical arrangement of the spots, 
bands, and stripes to be recognized in the furs of many of the lower 



ALBINISMUS. 423 

animals. The outline of the patch may be abrupt, or may gradually 
shade into that of the adjacent integument. At times, islands of 
pigmented skin are visible within the non-pigmented areas. The 
changes in these patches daring later life may be insignificant, or 
they may individually increase in size with age, or even multiply. 
Rarely they regain pigment in later life. Iu no case is there an 
excess of pigment deposited at the border of the patch. 
This condition is practically remediless. 

Albinismus. 

. Lat. albus, white. 

Albinismus is a congenital cutaneous achromia, characterized by universal 
defect of pigment, unaccompanied by textural changes in the skin. 

Symptoms. — The term albinismus is limited to the congenital con- 
ditions of achromia induced by universal failure of cutaneous 
pigment. 

This deformity is peculiar to individuals known as Albinoes, 
isolated instances of this anomaly occurring in all races, but more 
frequently among those having normally a hyperpigmentation of the 
skin, such as negroes. In the subjects of this anomaly, the skin 
has a milky-whitish, transparent, or rosy- tinted hue, and is usually 
of delicate texture; the hairs are silky and yellowish, whitish, or 
snowy-white in color; the iris, transparent or pinkish ; and the pupil, 
in consequence of the defect of pigment in the choroid, is also reddish 
or pinkish. There is, as a result, nyctalopia and heliophobia with 
frequent nictitation, pupillary variations, and the semblance of 
myopia. 

The pinkish hue of the skin is, in these individuals, due only to 
its translucency and vascularity. In no other respect, save as to 
pigment anomaly, does the skin of the healthy albino indicate disease ; 
but the majority of persons thus deformed are far from vigorous. 

In albinismus the defective condition of the pigment is usually 
unchanged throughout life. The causes of the deformity are 
unknown. The few cases of inherited albinismus on record are not 
sufficient to establish a law of inheritance in the face of many 
instances where such transmissibility has not occurred. The union 
of a male or female albino with an individual of normal color has 
been repeatedly followed by offspring without pigmentary peculi- 
arities. 

The condition is remediless ; though it is probable that transfusion 
with the blood of a vigorous black-skinned African would largely 
modify the color characteristics of the pure albino. 



424 DISEASES OF THE SKIN. 

Vitiligo. 

Lat. vitium, a blemish. 

Vitiligo is an acquired cutaneous achromia, exhibited in single or multiple, 
variously shaped and sized patches, unaccompanied by textural change in 
the >kin, and usually bordered by tissues exhibiting pigmentary excess. 

Symptoms. — The disorder is one observed among the several races, 
often in the negro, and not rarely among those of Aryan descent. It 
commonly occurs without the slightest appreciable disorder, subjective 
or objective, save that betrayed to the eye in the discoloration of the 
skin. One or several roundish, or very irregularly shaped, smooth, 
and well-defined, pale, or milky-white lines, streaks, or disks appear, 
often bordered at the periphery by an integument which assumes a 
light or dark brown or chocolate shade, this hue being by contrast 
most noticeable immediately at the contour of the patch, and imper- 
ceptibly fading into the normal color of the outlying integument. 
The hairs or lanugo filaments growing from the affected area may or 
may not be blanched. Most commonly they are; a condition par- 
ticularly conspicuous when, as is not rarely observed, a vitiligiuous 
disk extends from the back or side of the neck, well into the scalp, in 
which case the outline of that portion of the scalp involved is clearly 
defined by the whitened pilary growth. 

Lesser describes a condition termed by him " Poliosis Circumscripta 
Acquisita," in which the hairs were thus blanched in a single area of 
an unaffected scalp, an observation which the author has confirmed 
in a single case. 

The surfaces thus blanched are otherwise unchanged. In point of 
subjective and objective sensation, secretion from the follicles, and the 
condition of both epidermis and corium, aside from the dyschromia 
there is no departure from a normal standard. The disease may 
progress by the coalescence of relatively small areas of involvement 
till a large portion of the trunk, thighs, or buttocks is involved. 
Hall 1 reports the case of a dark mulatto who became " perfectly 
white" with the exception of a patch on the chin. Levy 2 reports 
three instances of total disappearance of pigment. It is then, as 
Kaposi has well shown, that the eye of the observer is struck no 
longer by the unusual whiteness of the involved patches ; but this 
whiteness being generalized and apparently that proper to the person, 
by the intermediate peripheral belts of a deeper and unusual color. 
The greater portion of the surface of the body may be finally thus 
involved. The most common seats of the disease are the face, the 
neck, the backs of the hands, and the extremities ; and in these, 
since the course of the disease is exceedingly slow, there may be 



1 Louisville Med. News, 1880, x. p. 148. 

- Receuil de Mem. de Med. de Chirurg et de Pharm. mil., 1865. 



VITILIGO. 



425 



Fig. 51. 



for years no apparent extension of any involved area. Upon the backs 
of the hands the disfigurement is usually more conspicuous at some 
seasons of the year than at others, a circumstance which probably ex- 
plains the reported instances of recurrence 
and total disappearance of the disease in suc- 
cessive years. These changes are probably 
due to the influence of the sweat in washing 
the pigment to the surface. Such an effect 
would, of course, render the hyper-pigmented 
peripheral zone of a vitiliginous disk much 
the more conspicuous. 

The health of the subjects of this disorder 
is usually unimpaired. A morbid mental 
condition is often produced when the disfig- 
urement involves the facial region, especially 
in women of middle life. 

As in several of the other pigmentary dis- 
orders of the skin, the patches of vitiligo 
may be symmetrical in distribution, with 
their outlines limited to the areas supplied 
by certain nerves. Lesser, however, attrib- 
utes this peculiarity to the symmetrical ana- 
tomical relations of the skin in symmetrical 
regions of the body, an explanation which 
will not suffice for all cases. 

The course of the disorder is evidently 
toward increase even where all the pigment 
is not removed from the surface. Generally 
a term is reached beyond which the atrophy 
does not progress. In exceptional cases the 
parts which have lost their pigment again 
acquire it. 

Patients of lymphatic temperament and 
blonde complexion (often they are women in 
early adult life) will occasionally apply to a 
physician for relief of dark patches on the 
skin of the face. Examination of these 
faces often discloses faint lines, ribbons, or 
streaks of pigment about one or both cheeks, 

the temples, or the lips. But a yet more careful scrutiny recognizes 
an undue whiteness of the skin, with exceedingly faint and irregular 
outline near or next to these pigmented portions of which complaint 
is made. I am inclined to set all these cases down as instances of 
vitiligo, even though they rarely exhibit the definite roundish contour 
of the typical patch of the disease. 

In some patients vitiligo is most conspicuous in summer ; in others, 
this occurs in winter. These peculiarities may depend upon changes 
either in the pigmented or unpigmented portions of the skin. 




Vitiligo in a Negro boy. 
Piffard's case. 



426 DISEASES OF THE SKIN. 

Etiology. — Vitiligo occurs in both sexes, and in individuals of all 
complexions and ages ; though it is commonly observed in early or 
middle life. It is at times coincident with scleroderma, morphcea, 
lepra, variola, and other diseases with similar cutaneous symptoms, 
though it occurs independently of all such. Its etiology must be 
regarded as obscure, unless the strong probabilities in favor of its 
occurrence under the influence of perturbed innervation be accepted 
as conclusive. I am strongly inclined to believe that the disorder is 
of more frequent occurrence than dermatological statistics tend to 
show. Many persons who are the subjects of vitiligo of an incon- 
spicuous part of the body, do not consult a physician with regard to 
the nature of the disease, as it occasions no physical distress. Close 
observation of the people with whom one comes in contact in public 
will often verify this fact. 

Pathology. — The pathological anatomy of vitiligo may one day be 
described in the changes which occur in the trophic nerves supplying 
the skin. At present, the cutaneous changes alone are recognized; 
and these are, probably, as regards the pigment, neither strictly 
atrophic nor hypertrophic. It is true that there is an apparent 
atrophy in one portion of the skin, and an apparent hypertrophy in 
another; but this may be merely in cases falling short of complete 
pigment atrophy, a dystrophia or ataxia of the epidermis, a disturb- 
ance of arrangement and distribution, as of the blood in the face, in 
certain cardiac diseases, when the skin is temporarily streaked or 
mottled by the irregularity in the distribution of the circulating fluid. 
Under the microscope no change is recognized in the skin beyond the 
absence of pigment. 

Diagnosis. — Mr. Hutchinson, of London, has devoted an entire 
chapter in his valuable Lectures on Clinical Surgery 1 to the impor- 
tance of the diagnosis between leucoderma and white leprosy ; yet it 
seems incredible that the symptoms characteristic of a systemic 
disease could be confounded with those described above, where there 
is no cutaneous anaesthesia or structural change in the integument. 
This latter is, in fact, the basis of discrimination between all purely 
pigmentary and all non-pigmentary changes in the skin-color, separ- 
ating them widely from parasitic diseases (tinea versicolor), morphcea, 
lepra, and syphilis. From the chloasmata, which are always accom- 
panied by hyper-pigmentation, vitiligo is readily differentiated. 

Treatment. — Much chagrin will be saved both physician and 
patient, by practically regarding vitiligo as not amenable to treat- 
ment. Patients occasionally recover while under treatment; the 
latter has, however, generally contributed but very little to the result. 
Arsenic and iron internally, recommended highly by some authors, 
have repeatedly failed to accomplish any appreciable results as regards 
dyschromia. By efforts directed to the removal of the hyper- 
pigmentation in the border of the achromic patches, the disfigurement 
may be somewhat lessened. The method of arriving at this end is 

i Churchill, London, 1878. 



CANITIES. 427 

described in connection with the treatment of chloasma. It is pos- 
sible that further experimentation with hypodermatic injections of 
pilocarpine, which have in a limited number of cases been followed 
by disappearance of the disease, may warrant a less unfavorable view 
of the results of treatment. 

Prognosis. — The health of the subject of the malady is not im- 
paired. The disease is practically incurable, progressing usually till 
it has obtained a maximum of development ; and then, as a rule, 
remaining unchanged throughout life. 

Canities. 

Lat. canus, white. 

Canities is that condition of the hairs in which they become in various degrees 
decolorized as the result of atrophy of their pigment. 

Symptoms. — In Canities, or Poliosis, hairs appear in all shades of 
whiteness, from dirty-gray to silvery- white, and this either as a general 
or partial, congenital or acquired, physiological or pathological, 
prematurely, rapidly, or gradually acquired condition. General 
congenital whiteness of the hairs is seen in albinismus, where pig- 
ment has never been supplied to the filaments. Partial congenital 
whiteness is occasionally seen, in meshes limited in size, varying in 
color from a pure white to a deeper hue, which from birth refuse to 
receive pigment in due proportion, and thus contrast strangely with 
the pigmented filaments by which they are surrounded. 

Physiological decoloration of the hairs in variable shades is the 
well-known result of advancing years. When premature, it may be 
considered as resulting from pathological causes, or due to other indi- 
vidual or inherited peculiarities. It may occur gradually or sud- 
denly ; in the former case, the hairs usually pass through varying 
shades of gray to white, and this at any period after puberty though 
usually after middle life is reached. Recurrence to the darker shades 
is rarely noted. Leonard, of Detroit, 1 cites a number of curious 
instances in which changes of this sort have occurred. Generally, 
however, canities of advanced years is progressive and permanent, 
occurring earliest on the temples and the beard of man, then involving 
the vertex of the head. Finally, the hairs of the entire surface 
undergo a similar pigmentary loss. 

It should be remembered that the coloring of the hairs of the head 
is, to a greater extent than is commonly appreciated, subject to vari- 
ation from the operation of external causes. Thus washing the hair 
with alkaline solutions has a bleaching effect, while profuse sweating, 
inunction with fats, subjection to smoke, and the temperature changes 
of the summer, have the contrary influence, the last named being 
possibly due to the increased sweating in the hot season. 

Cases of sudden blanching of the hairs, occurring, for example, in 
a single night, are sufficiently numerous and well authenticated to be 

i The Hair, etc., Detroit, 1880. 



428 DISEASES OF THE SKIN. 

admitted as among the rare possibilities of a clinical experience. 
Nervous disorders, both centric and peripheral, such as long-con- 
tinued mental depression, melancholia, paralysis, neuralgia, and 
traumatism of nerves or of nervous centres, may be followed by more 
or less rapid, general or partial, and permanent canities. The same 
result may follow wasting disorders, such as typhoid fever, in which 
cases, as distinguished from the others, properly pigmented hairs often 
replace eventually those which were white. It is well known that 
the first hairs springing from a patch of alopecia areata where repair 
is in progress, are often white or whitish, and replaced later by those 
of normal color. 

Laudois has shown that many instances of suddenly occurring 
canities depend solely upon the rapid appearance of air-bubbles in the 
shaft, in excess of the average number. Hairs whitened in alternate 
patches, rings, nodes, or spots have been described by Landois, 
Karsch, Riehelot, Spiess, and others. 

Etiology. — Whitening of the hair may be senile in origiu, in which 
case it is customary to declare it to be physiological ; or be due to 
heredity; to deficient nutrition or innervation of the hair-follieles ; 
to functional or organic nervous affections (fright, facial atrophy, etc.) ; 
or to local chemical action upon the hairs. Premature canities in 
young adults is often associated with the occupations of life, being 
much more common in men who from necessity have the head habit- 
ually covered, and who yet lead sedentary lives. 

Pathology. — The pigment substance of the hairs is both cellular and 
intercellular in its distribution, and is supplied by the papilla. De- 
coloration of the hairs may be due to failure of supply or removal 
of pigment ; to unevenuess of the hair surface (by which the light is 
refracted) ; or to air-bubbles between and within the fibre-cells. In 
senile and presenile decolorations, there is commonly actual diminu- 
tion of pigment, which has been ascribed to failure of the papilla to 
produce it. Sudden canities is ascribed to the sudden appearance of 
air-bubbles in quantity in the shafts of the hairs. Alternations of 
color in the hairs are ascribed to successive periods of activity and 
rest in the pigment-producing function of the follicle. 

Treatment. — McCall Anderson, while admitting that the treatment 
of canities is unsatisfactory, suggests, in cases of accidental presenile 
blanching, strict attention to the general health, arsenic internally, 
and local stimulation, as in alopecia simplex. But the chief means 
of remedying premature canities is by the action of dyes, and these 
are, in the main, compounded of solutions of nitrate of silver, 
acetate of lead, and the sulphate of iron. The chief objections to 
their use are the disagreeable coloring of the scalp which results from 
incautious use of the dye, and the consequent liability to irritation 
of the surface. When applied to the hair alone, these substances are 
not known to have a deleterious effect upon the health. Kaposi gives 
the following formulae for hair dyes : 



ALOPECIA. 429 

To obtain a black color — 

R . Argent, nitrat. gr. xv ; 1 

Ammon. carb. grs. xxij ; 1 

Unguent, adipis §j ; 32 

R . Argent, nit. gj ; 4 

Plumb, acetas gr. xv ; 1 

Aq. Cologn. gtt. xv; 1 

Aq. ros. ad f^iij ; 96 



M. 



M. 



To obtain a brown shade — 

R. Acid, pyrc-gall. gr. xv; ll 

Aq. Cologn. 3ss; 2 

Aq. ros. gjss; 48 1 M. 

Anderson first applies a lotion of the bichloride of mercury, two 
grains to the ounce (0.133-32.), and follows this with a solution of 
the hyposulphite of sodium, one drachm to the ounce (4.-32.), for 
the production of a jet-black shade. 



2. Of Hair. 

Alopecia. 

Gr. alunriZ, a fox. 

Alopecia is a physiological or pathological, symmetrical or asymmetrical, 
partial or complete deficiency of hair. 

Alopecia, Calvities, Defluvium Capillorum, or Deficiency of Hair, 
may be due to arrested pilary development at birth, or to any cause 
interfering with the regular physiological process by which hairs are 
constantly shed and replaced by new filaments. 

Congenital Alopecia. — In rare cases, there is a partial or com- 
plete absence of hairs at birth, in consequeuce of an arrested develop- 
ment of the pilary system. Generally, however, these appendages 
of the skin are merely of tardy appearance, their eruption being 
extraordinarily delayed, as in cases of retarded dentition. 

When this condition persists to adult years, as is very rarely the 
case, neither hairs nor teeth may be formed, as in Danz's observa- 
tion. The author has had a child seven years of age presented at 
his clinic, with only a wisp of white hairs upon the vertex of the 



In localized congenital alopecia, hairs rarely develop after matu- 
rity, and here also abnormalities of teeth may be coincident features. 
In a case examined by Schede, the sebaceous glands were found 
opening on the free surface of the skin. In the deeper part of the 
cutis, straight or convoluted hair-rudiments were visible in the 
tubules, without perceptible internal cavity, which corresponded to 
the external root-sheath. 



430 DISEASES OF THE SKIN. 

Senile Alopecia. — The baldness of old age, whet her occurring 
upon the vertex, so as to produce a tonsure like that of the priest, or 
whether limited to the frontal region, or so extensive as to involve 
nearly the entire calvarium, leaving a fringe of hairs at the occiput 

and temples merely, is always remarkable for its symmetry. There 
is hence a certain degree of dignity added to the appearance of the 

head, which an asymmetrical loss of hair could not produce. It may 
occur at varying ages of advanced life, and is quite frequently trace- 
able to an early seborrhoea sicca or alopecia furfuracea. It is much 
more common in men than in women; and this largely because of 
the difference in the manner of covering the head in the two sexes, 
women usually wearing an exceedingly light dress for the head, 
while men encase the latter with tight-fitting caps or hats which 
interfere with proper aeration of the scalp. Individuals of the male 
sex, also, in consequence of their usually wearing the hair short, 
bestow far less time upon the care and dressing of it. In uncivilized 
races, where these differences are less marked, and where men pay 
great attention to the ornamentation of the scalp, senile baldness is 
of less frequent occurrence. 

The bald surface is, as a rule, smooth and shining; it is occasion- 
ally the seat of a seborrhoea oleosa. The hair-follicles, with their 
accessory sebaceous glands, and occasionally the skin itself are often 
in a state of atrophy, though there may be dilatation of the sebaceous 
glands. There is commonly some blanching of the hairs, which are 
gradually shed, as also of those which remain, though this is not 
constant. These conditions are much less frequent upon the surface 
covered by the beard, and pubic and axillary hairs, where, according 
to Michelson, the hairs in advanced years are often denser than at 
other periods of life. 

Premature or Presenile Alopecia, or premature calvities, is 
that form of acquired baldness which occurs in individuals who 
have not attained advanced years. It may be either idiopathic or 
symptomatic. 

The idiopathic variety does not originate in the diseases of the 
scalp or of the general economy which are recognized as effective in 
the production of other forms of baldness. It is, as with senile 
alopecia, more common in men than in women, and is, in the former 
sex, decidedly prevalent among those leading sedentary lives. The 
loss of hair may be produced either rapidly, or, more commonly, 
slowly, and at any period after the. puberal epoch. The pilary 
growth may gradually and evenly recede from the forehead, or, what 
is more frequent, recede on either side of the median line, leaving a 
more vigorous crop extending centrally toward the root of the nose, 
or produce the effect of the tonsure described above. It is always 
symmetrical, and usually remediless, partial calvities being the per- 
manent result of the process. In many families, there is a predis- 
position to this premature loss of hair, which may be recognized in 
the males of succeeding generations. 



ALOPECIA. 431 

Symptomatic premature alopecia is the frequent result of a series 
of local and general disorders which vary in their gravity. Sudden 
and gradual symmetrical thinning of the hairs or complete baldness, 
is sufficiently common as the result of seborrhoea sicca, psoriasis, and 
other cutaneous affections of the scalp; the asymmetrical forms being 
more common in asymmetrical scalp diseases, such as those resulting 
from the destructive action of the vegetable parasites. Rarely, how- 
ever, asymmetrical seborrhoea, occurring in patches upon the side 
of the head, may produce such disfigurement. Among the systemic 
disorders which have this effect, may be named almost all severe 
febrile processes, including the exanthemata, profound disorders of 
the nervous centres, lepra, and syphilis. In the last-named disease it 
may occur as a precocious or tardy symptom, the former being always 
symmetrical, variable as to the degree of loss, rarely so severe as to 
cause baldness, and, occurring as it does usually in early adult years, 
generally quite remediable. The tardy form, on the other hand, 
is usually associated with the evolution or destructive involution of 
gummata of the scalp, and the resulting baldness is often permanent. 

The forms of alopecia described above as encountered upon the 
scalp, may involve also other hairy portions of the body, as of the 
axillae and pubis; and these also in variable degrees. 

Pathology. — In senile and premature alopecia, a fibrous endarteritis 
is described by Michelson as first occurring to narrow the lumen of 
the vessels, which starves the follicular and peri -follicular tissues till 
an atrophy results. The epidermis becomes thinned ; the derma 
contracts ; the hair-follicles shrink, while their funnel-shaped orifices, 
occupied with loose horny masses or lanugo hairs, remain patulous. 
Convolutions of pigmented, roundish nuclei, aborted results of hair- 
formation, may rarely be recognized at the base of the empty hair-sacs. 
The coil- and sebaceous glands and muscles are but slightly altered. 

Treatment. — The treatment of alopecia in general, is that which 
stimulates the nutrition of the hair-follicle by producing in its peri- 
phery a species of transitory and artificial hypersemia. This is 
usually accomplished by friction of the scalp with a brush, aided by 
the local employment of one or more alcoholic, oily, alkaline, and 
other stimulating applications described below. The general health 
must in such cases receive special attention. A large number of 
individuals suffering from premature baldness have a distaste for fat ; 
and the ingestion of cod-liver and other nutritious oils, fat meat, or 
linseed and linseed oils, as recommended by Sherwell, is for such 
patients advisable. Iron, strychnia, tar, phosphorus, and arsenic, 
often meet the indications presented. 

A scanty crop of short, soft, downy hairs may, however, push for 
a time to the surface, but soon yield before the inactivity of the 
follicles in which they are implanted. Inasmuch, however, as excep- 
tionally brilliant results arc occasionally obtained by treatment, the 
latter is always deserving of a trial. When the alopecia is symp- 
tomatic of some local disease of the scalp, the latter of course is first 
to be relieved by the measures, appropriate for each, as, for example, 



432 



DISEASES OF THE SKIN. 



the use of parasiticides in those of parasitic origin. The total or 
partial symmetrical losses of hair occurring in the course of systemic 
disorders have a much more hopeful prognosis. Exception, how- 
ever, is to he made of the tardy syphilitic alopecia associated with 
local scalp lesions or profound cachexia. In all forms of syphilitic 
alopecia, local as well as constitutional treatment is indicated. 

Local treatment may often be preceded by shampooing with either 
the Sarg fluid soap, or combinations of glycerine, alcohol, and sapo 
viridis to meet the requirements of individual cases. The scalp, 
after all such shampooings, should be anointed with lanoliue, plain 
or salicylated ; vaseline; the oil of benne; or scented castor oil. In 
obstinate cases the nail-brush may be vigorously used over insensitive 
scalps at the time of the shampooing. The salve used may be often 
advantageously medicated with sulphur, chrysarobin, tar, cantharides, 
or mercury. Formulae for lotions and salves to be used in this way, 
are appended : 



R. 
Fo 


Hydrarg. chlorid. corros. 
Spts. vin. rectif. 
Glycerin. 
Aq. ros. 
r external use over the scalp. 


grs. v ; 

|ij; 

svj; 


64 

16 

192 


33 

M. 


B 


Picis liquid, [vel. ol. rusci] 
01. lavendul. 
01. pin. sylvestr. 


aa3j; 
5vj; 


4 

192 M. 
[Piffard.J 


R 


Hydrarg. chlorid. init. 
Hydrarg. amnion, chlor. 
Vaselin. 


Bij; 

ad Ij ; 


5| 

2 66 
32 1 M. 
[Bronson.] 


R 


01. sabinse gtt. 
Spts. vin. rectif. 


v-xxx ; 

3J; 


133-2. 
32j M. 

[Pincus.] 


R 


Hydrarg. bichlorid. 
Cantharid. tinct. 
Medull. bovis. 
01. rosar. 


gr. ss ; 
f3j; 

q. s. ; 


1032 

4 
16 

M. 
[Van Harlingen.] 


R 


Acid, chrysophanic. 

Glycerin. 

Vaselin. 


gr. x; 
n\.xl; 
3vij; 


166 
266 
.28| M. 
[Anderson.] 


R 


Sulphur, prsecip. 
Ungt. aq. ros. | 
Vaselin. j 


3j; 

aa 3ss ; 


4 
16 


M. 



Andre is said to have induced an abundant growth of hair in an 
obstinate case of total baldness by hypodermatic injections of the 
muriate of pilocarpine, from one-eighth to one-fourth (0.008-0.016) 
of a grain being injected on each occasion. 

The treatment of alopecia is that also of alopecia furfuracea, and 
alopecia areata. 



ALOPECIA. 433 



Alopecia Furfuracea, 

or Pityriasis Capitis, or Alopecia Pityrodes Capillitii. Under this 
title is included that loss of hair, varying greatly in degree from 
moderate thinning of the growth to considerable symmetrical bald- 
ness, usually of the vertex, which, at the onset, is scarcely distin- 
guishable from alopecia simplex, alopecia prematura or prsesenilis, 
and seborrhcea of the scalp in some of its forms. It is exceedingly 
common, especially in men. 

The disorder, essentially chronic in course, is usually first mani- 
fested in early adult life, though persons of both sexes, from twelve 
to fifteen years of age, may at these ages display typical forms of the 
disease. After some months or years, the subject of the affection 
discovers a relatively large loss of hairs from the scalp producing 
thinness of the growth upon the vertex, near the brow or over the 
temples. The hairs, when examined in situ upon the scalp, are 
shortened and rebellious to the comb and brush, projecting stiffly 
from the brushed surface, being also harsh, lustreless, and rarely well 
anointed with sebum. Those shed from the scalp, especially of men, 
are found to be nearer in type to the lanugo or downy hairs than 
those which fall physiologically from a vigorous growth of hair in a 
healthy subject; that is, they are short, thin, pointed, and often with 
an indistinct medulla. 

At the same time the scalp is in process of incessant desquama- 
tion, the scales being of pityriasic type, and exceedingly abundant 
so long as the alopecia is not complete, after which, the epidermal 
catarrh promptly disappears. The mealy, bran-like scales are shed 
in a fine shower upon the clothing of the patient, and, the disease 
being more common in men than in women, its traces are often dis- 
tinct upon the collar of the coat after the fingers have been passed 
through the scalp. The same flour-like, whitish and grayish scales 
are distinct and plentiful among the hairs to which they cling, and 
also can be recognized over the scalp surface when the latter is 
inspected with care. Greasy conditions of this product of secretion 
upon the scalp are due to complications with a seborrhea of this 
region, and the reader is urged to consult the chapter devoted to that 
malady in order to study this subject from its several pathological 
sides. According to Pincus, three-fifths by weight of the scales fur- 
nished by the scalp in this condition, are inspissated products of 
sebaceous secretion. 

Often, however (and it is this important feature which justifies the 
separate consideration of alopecia furfuracea and seborrhoea capitis), 
the scales are true squamse; dry, corneous, and epithelial, rather 
than fatty and seborrheic. The subjective sensations are then 
usually marked ; the scalp is often scratched and torn by the nails, 
and is, in some cases, reddened and thickened. There may be also 
decided general cachexia. Among women the patients are often 
nervous and sallow, with a long history of distressing headache, 



434 DISEASES OF THE SKIN. 

uterine hemorrhage, or hepatic disorder. These are simply states in 
which there is malnutrition of the scalp. 

The scalp may or may not he the seat of perspiration. Eczema, 
of pustular type, occasionally complicates these cases. 

Etiology. — The disorder may be due to inheritance, to any systemic 
affection impairing the bodily vigor, to long-continued neglect of the 
hygiene of the scalp, or to such diseases of women as are accompanied 
by menstrual irregularities. The confinement necessitated by seden- 
tary occupations of life; those trade- and professions which permit 
or require the constant covering of the head of men ; and the wearing 
of heavy hats or bonnets interfering with the aeration of the scalp, 
all furnish conditions for the occurrence of the disease. 

In 1882, Lassar and Bishop produced alopecia by rubbing upon 
the sound surface of the skin of animals the epidermic detritus and 
hairs furnished by a patient affected with the disease. This lends 
color to the possibilities of contagion which should not be ignored. 

Pathology. — According to Pincus, the vessels of the scalp are 
unaltered, but the corium beneath the affected surface is thinned in 
proportion to the severity of the disease. Nothing characteristic can 
be discovered in the hairs removed from an affected patch. 

Diagnosis. — The disease is distinguished from seborrhoea of the 
scalp by the epithelial character of a great part of the dry discharge 
occurring symmetrically from the scalp surface, coupled with the 
symmetrical and largely vertical alopecia. The asymmetrical greasy 
patches of pure seborrhoea capitis, pasting the hairs to the scalp, 
which may be limited to the occipital or temporal region of one side, 
are strikingly different. Michelson and Pincus place reliance in 
establishing a diagnosis, upon the firmer attachment of the scalp and 
the discovery upon four successive days of a proportion of one-eighth 
of pointed hairs to the entire pilary loss, with an average length of 
thirteen centimetres. 

Treatment. — The general and local treatment of alopecia furfuracea 
is practically that of alopecia simplex, alopecia areata, and seborrhcea 
of the scalp. 

Pincus applies upon compresses the sodium bicarbonate in solution 
sufficiently concentrated to stimulate but not redden non-hairy por- 
tions of the skin. Sulphur, tannin, the oil of savin, the bichloride 
of mercury, tar, naphthol, resorcin, the peroxide of hydrogen (in two 
volumes), and iehthvol have all been successfully employed in the 
management of these cases. Each is best preceded by the shampoo- 
ing described in the preceding chapter. Schmitz, Schiiller, and 
Andre have all reported excellent results from hypodermatic injec- 
tions twice weekly of one-twelfth to one-sixth of a grain (0.005- 
0.010) of the muriate of pilocarpine in distilled water. 

No remedy has a higher and more established value in the local 
management of these cases, whether in an early or late stage, than 
sulphur. In the strength of from one-half to one drachm (2.-4.) of 
precipitated sulphur to the ounce (32.) of vaseline or lauoline, it 
should be well rubbed into the scalp after each shampooing. When 



ALOPECIA AREATA. 435 

there is marked improvement of the pityriasic catarrh, one of the 
stimulating lotions may be used that are described in the pages devoted 
to the other varieties of alopecia. 

Alopecia Areata. 

Lat. area, a vacant space [arere, to wither, Fox). 

Alopecia Areata is a disease of the pilary follicles characterized by the sudden 
occurrence of general and symmetrical, or partial and asymmetrical bald- 
ness, the latter exhibited in distinctly circumscribed, smooth, whitish 
patches, which are, in typical cases, completely destitute of hair. 

Symptoms. — This disorder, which is more common than is gener- 
ally believed by physicians, may be, at its outset, preceded or accom- 
panied by symptoms of ill-health, such as headache, malaise, inappe- 
tence, loss of flesh, or malnutrition. In yet other cases, cephalalgia, 
paresthesia, pruritus, aud formication of the skin of the scalp and 
other regions indicate some disturbance of the nervous centres. 

Often, however, the patients of this class are in sound health, the 
disease then manifesting itself by the sudden and complete loss of 
hair over a circumscribed patch, usually upon one side of the scalp, 
so rapidly effected that they often describe a first discovery of the 
fact at the toilet of the morning. After a variable period of time, 
other patches of baldness may occur, all of the hairy portions of the 
body being liable to the affection, the scalp first in order, next the 
beard, then the genitalia, axilla?, brows, eyelids, and the general sur- 
face of the body. In early childhood cases occur in which the closest 
scrutiny with a glass fails to detect a single filament of hair upon any 
portion of the skin. 

The patches may be roundish, ovalish, or irregularly shaped, and 
may vary greatly in size, from that of a small coin upward. They 
may be so numerous as to disfigure greatly the entire scalp ; and 
though these touch at the borders when thus numerous, they can 
scarcely be said to coalesce, as the individual elementary areas are 
usually recognizable. Their surface is smooth, whitish, and often 
perfectly destitute of hairs; it is rarely tumid, and slightly reddened. 
The hairs at the periphery are usually of full length and fixed in situ, 
but are occasionally fragile, and readily withdrawn from their follicles. 
Stumps of such friable hairs may be at times seen at the margin of 
the patch. In point of abnormal subjective sensations, temperature, 
or disease of the surface from which the hairs have fallen, there is, as 
a rule, complete absence of symptoms. The skin, when the evolution 
of the disease is complete, is usually normal to the touch, and pliable. 
Occasionally it is anaemic, thinned, and more movable over the corium 
than in the scalp which is not the seat of the disease. 

In incomplete evolution and in periods of repair, downy hairs may 
appear upon the surface, at times considerably differing in color from 
those springing from unaltered regions of the scalp. 

The loss of hair from the surface may be : rarely, gradual ; pre- 
ceded by mild pruritus (Besnier et Doyon); or followed by anses- 



436 DISEASES OF THE SKIN. 

thesia (Neumann). Its apogee once attained, the course of the disease 
is variable; it may persist for periods without apparent change; or 
new patches may form while those of an older date either proceed to 
exhibit wholly or in part the pilary growth; or, this latter accom- 
plished, suffer a fresh loss by relapse. Shifting areas of the disease 
may, without question, in this manner invade the entire surface of 
the scalp, which yet at any one moment of time may exhibit a loss 
of but the half of its hirsute covering. 

There is some reason for believing that the disease has a relatively 
fixed period of evolution, though the exact limits of the latter are not 
known. Few individuals suffer less than one year ; the most are 
relieved within a period of two years. These remarks, however, 
apply to the asymmetrical forms of the disease in the relatively young. 
The symmetrical alopecia areata of the middle-aged is, in my experi- 
ence, a far more formidable affection. 

Few diseases are the source of greater mental distress than those of 
the class now under consideration. The prominent deformity thus 
occasioned debars the subject of the malady from social relations of 
many kinds, and this intensifies the morbid feeling which every 
reflected view of the head awakens. This is particularly true of 
women. The successful management of these cases calls often for the 
supporting assurances of the practitioner. 

Etiology. — The causes of the disease are obscure. It is not trans- 
mitted by heredity nor by contagion; and it is not due to the 
presence of a parasite. It occurs with ecpiial proportion in the two 
sexes ; and among these, irrespective of social condition. Of the 
partial and asymmetrical forms, the larger number of cases occur in 
young subjects, from childhood to early adult life. The severe 
and generalized forms are more often encountered in middle-aged 
persons. In the latter class especially, it is occasionally observed to 
follow the obscure disorders of the nervous centres due to sudden or 
prolonged undue excitation. In young subjects one may often dis- 
cover a peculiar repugnance to the ingestion of fat and meat, a point 
to which attention is called in considering alopecia simplex. 

The neurotic explanation of this disorder is more geuerally 
accepted as facts accumulate bearing on its etiology. The nervous 
symptoms which often precede or accompany the appearance of the 
bald patches are strikingly suggestive, and led Von Barenspruug to 
announce his theory of "inherited innervation " as a cause of the 
malady. Further, the occurrence of the disease after shock of the 
nervous centres is significant. 

Collier 1 cites two cases in which alopecia areata followed a blow 
upon the temporal region, and Sir Dyce Duckworth reports the case of 
a gentleman who sustained an injury to the head in a fall from a dog- 
cart, who suffered as a result from permanent loss of hair. OveraP 
has reported a similar instance; Joseph 3 has produced the disease by 
section of nerves in a cat. 

1 Lancet, Amer. Ed., August, 1881, p. 130. - Alien, and Neurol., St. Louie, 1886 

3 Ontralb. f. meil. Wissenscliaft , 1880, No. 11. 



ALOPECIA AREATA. 437 

On the other hand, v. Sehlen, 1 in 1885, exhibited in the Medical 
Congress at Strasbourg, micrococci about the sheaths and roots of the 
hairs, which he claimed to have demonstrated to be the cause of the 
disease. 

Pathology. — The anatomical lesions which produce alopecia areata 
have not been recognized. The hairs fallen from the surface, when 
examined with the microscrope, are seen to be atrophied in the bulb 
and shaft, though Rindfleisch describes in certain cases a node-like 
enlargement of the hair-shaft after its escape from the follicle. 
Fracture of the shaft is in some cases also noted, evidently an acci- 
dent of the process. No parasite can be discovered in uncomplicated 
cases. I have in one instance detected spores and mycelia of the 
trichophyton in the hairs, a coincidence of two disorders which has 
been observed by others. 

In default of all positive knowledge on the subject, the majority 
of dermatologists have assumed the disease to be a trophoneurosis, a 
view sustained by the etiological history of certain cases. 

Michelson, however, regards the vasomotor nerves as presiding 
over the nutritive changes determining the loss of hairs. Schultze 
recognized some thinning of the scalp in sections examined by him. 
Future investigation may establish some difference other than that of 
degree between the partial asymmetrical disease of the young and the 
more general symmetrical affection of middle life; in which the entire 
scalp, lids, brows, pubes, and axilla? are completely shorn of their 
filaments. It is, however, held to-day that all forms of alopecia are 
parasitic in origin and are therefore all related. 

Diagnosis. — Alopecia areata is to be distinguished from vitiligo of 
the hairy portions of the surface by the preservation of the pilary 
growth in the disease last named, the filaments, moreover, having 
usually a blanched and whitened look, due to the absence of pigment. 

From ringworm aud favus of the scalp the disease in question is 
readily differentiated, by the suddenness of its onset ; the absence of 
all stumps of hairs, scales, crusts, and evidences of irritation in the 
involved area ; the whiteness, smoothness, and complete baldness of 
the latter; and, above all, by the failure to detect with the micro- 
scope the evidence of the presence of a vegetable parasite. 

The asymmetrical patches of seborrhoea of the scalp are recognized 
by the presence of the fatty plates pasting the hairs to the surface, as 
well as by the slow and very gradual onset of the disorder. 

Other forms of baldness than those named above are all of gradual 
and, in their early stages, of symmetrical development. Those re- 
sulting from traumatic injuries of the scalp, with cicatricial results, 
are easily determined as having such an origin. 

Treatment. — One must necessarily view with some distrust all 
treatment for that disease which in the course of months or years 
usually terminates in spontaneous recovery, and in the meantime 
may bid defiance to each and every therapeutic measure. Neverthe- 

1 Anna], tie Derm, et de Syph., June, 1886. 



438 



DISEASES OF THE SKIN, 



less, persistent and hopeful management of even the apparently 
desperate cases is occasionally rewarded by such brilliant conse- 
quences that, however slight may be the foundation for a belief in 
the value of the therapy employed, it deserves recognition and trial. 

The hygienic management of every ease is a matter of great 
importance. Tobacco should in every form be denied to subjects 
of the disease addicted to its use. Iron, quinine, mix vomica, cod- 
liver oil, phosphorus ami the hypophosphites, arsenic, and strychnia 
are often indicated, and used with great benefit. 

The indication for local treatment is to increase the physiological 
afflux of blood to the hair-follicles. With this end in view, the 
affected part- are to he bathed daily in water as hot as can be toler- 
ated, then dried, and scrubbed with a stimulating lotion. The 
articles usually employed are alcohol, ether, turpentine, ammonia, 
camphor, cantiiarides, carbolic acid, oil of mace, croton oil, tincture 
of mix vomica, tincture of capsicum, tincture of aconite, castor oil, 
tar, iodine, sulphur, and the mercurials. All frequently fail. Several 
of these in combination seem at times to be of service. 

The following is a formula, the ingredients of which may be 
varied to suit the indications in different cases : 

R. 01. ricini f£ss; 16 

Acid, carbolic. 3j ; 4 

Cantharid. tinct. ^ss; 16 

01. rosmarin. gtt. xv; 1 

Spts. vin. rectif. adf|iv; 128 M. 

Sig. For external use over the scalp with friction. 

The formulae containing chrysophanic acid and the bichloride of 
mercury, given on a preceding page in connection with the treatment 
of alopecia furfuracea, are well worth trying. 

Dr. Nevins, of Liverpool, mops the entire surface with strong 
liquor ammonias. The speediest return of hair the author has ever 
observed in a patch of alopecia areata, followed a single application 
of pure creasote to the surface, resulting in moderate vesication. 
The spirit of turpentine has been similarly employed. 

Faradization of the scalp with a stiff wire brush, pushed to the 
point of producing moderate hyperemia, has been followed by excel- 
lent results. 

Wilson recommends: 



M. 



R. 01. amygd. dulc. 


«8; 


32 


Capsici tinct. 


f3ij ; 


8 


Liq. amnion, fort. 


flj; 


32 


Spts. rosmarin. 


f5v; 


160 


01. limon. 


f3j; 


4 


Here is another stimulating 


application : 




M. 01. terebinth. ) 






01. ricini { 


aa f,5ss ; 


16 


Origan i tinct, 


f3j; 


4 


01. camphorat. 


f.5J; 


32 


Liniment, volatil. 


ad f.^iij ; 


96 



M. 



Sig. For external use with a brush till the scalp is irritated. 



ALOPECIA AREATA. 439 

Repeated blisterings of the scalp with cantharidal collodion, the 
spirit of green soap, and petroleum have also been employed exter- 
nally with success. The ointment of chrysarobin has the disadvantage 
of staining not only the remaining hairs, but often the face in conse- 
quence of the frequency of its transmission to that locality by the 
medium of the hands. When patients, however, consent to its use, 
it is worthy of a trial, as its application has been speedily followed 
by a vigorous growth of new pilary filaments. Andre employed ten 
hypodermatic injections of muriate of pilocarpine in one-eighth grain 
(0.008) doses, which resulted, in the case of a middle-aged woman 
affected with total symmetrical baldness, in an abundant growth of 
hair. 

Lassar and Bishop 1 operated by first vigorously shampooing the 
entire scalp daily with a strong solution of tar soap for fifteen 
minutes ; rinsing next with an irrigator, by the aid of warm water, 
followed by cold water, and subsequently drying. Then a corrosive 
sublimate wash (1. : 300. adcle spts. cologniens., glycerin., aa 
100.) was applied, and the head again dried ; then a solution of 
naphthol (naphthol, 0.5; spts. dil., 70.; aq. dest., 30.) was rubbed 
in. Lastly, carbolized oil, 1J per cent., was poured slowly over the 
scalp, entering the cleansed and expanded orifices of the glands, so 
that seven drachms (28.) could be employed at a time. This was 
pursued daily for eight weeks. 

Prognosis. — From what precedes, it will be justly inferred that, as 
regards the relief of the baldness, the asymmetrical development of 
the patches in youth is much more favorable than the symmetrical 
general disease of middle life, the latter being often remediless. 
The prognosis of the same affection of the beard is quite favorable. 
In all cases, the practitioner should actively persevere to the end. 
In no case should any encouragement be given as to complete relief 
within the year, though such exceptionally short careers of the dis- 
ease are at times observed. 

The disease, when limited to the regions of the beard in young 
men, usually concludes its stadium in the course of about one year, 
with a favorable termination. Shaving should be regularly prac- 
tised, as the deformity is thus rendered somewhat less conspicuous, 
and the bald surface should be frequently stimulated with one or 
several of the topical applications named above. Alcoholic solutions 
of the mercuric bichloride, half to one grain (0.033-0.066) to the 
ounce (32.) are to be well rubbed over the patch or patches once 
or twice daily. The disease in this locality may coexist with benig- 
nant syphilis, the latter disease pursuing a career considerably 
shortened by vigorous treatment, while the former, none the less, 
endures from twelve to fourteen months, long after the syphilitic 
cachexia has been relieved. At the end of this time, recovery occurs 
precisely as in those cases which have presented no history of in- 
fection. 



440 DISEASES OF THE SKIN 

In all eases of implication of the head, where the scalp is involved 
in either sex, and where the peculiar hypochondriasis of the disease 
is developed, a wig should be worn for the sake of its moral effect 
upon the sufferer. For such, however, its use should be limited to 
social occasions, visits, etc., as the persistent wearing of a perruque 
indoors seems to lengthen somewhat the course of the disease. 

Alopecia Neurotica. — Under this title Michelson includes all 
cases of loss of hair, (1) coincident with or following traumatism of 
cerebral or peripheral nerves ; (2) those associated with diseases of 
the nervous system due to internal causes. As to the first class, 
instances of alopecia are given above, where, as in the case reported 
by Sir Dyce Duckworth, the loss followed a fall upon the head. 
Todd, Schultze, Fischer, and Michelson have also made observations 
of this character. In the second category are the local and general 
losses of hair reported as associated with melancholia, migraine, 
neuralgias of persistent type, and facial and other paralyses. In 
some of them the skin and panniculus adiposus have wasted, the 
hairs falling in stripes or ribbon-shaped streaks, with partial or 
complete canities of those left in the follicles. 

Atrophia Pilorum Propria. 

Atrophy of the hair may be either symptomatic or idiopathic. 
Illustrations of the first named condition are observed in phthisis, 
syphilis, seborrhcea, ringworm of the scalp, and almost all general 
diseases interfering with the nutrition of the pilary growth. The 
filaments then become dry, lustreless, friable in both longitudinal 
and transverse diameters, and diminished in each dimension. 

There are several recognized forms of idiopathic atrophy of the 
hair. One of these exists in those long hairs which are seen to be 
irregularly thinned or flattened in the shaft, and split at the point 
into two or more recurving fibrillffi, a condition noted, for the most 
part, in few hairs scattered among those of full development and 
vigor. This especially localized atrophy seems to be peculiar to one 
or more follicles merely ; and is quite analogous to the condition in 
which there appears among the vigorous pigmented hairs of early 
life, a single blanched filament. 

Under the title "An Undescribed Form of Atrophy of the Hair of 
the Beard," Duhring 1 gives the details of an exceedingly interesting 
<asc, in which either at the bulb or at a variable distance from it but 
within the follicle, there was fission of the hair filament into from 
two to four stalks with coincident atrophy of the bulb itself and 
consequent irritation of the surface. The patient exhibited to a 
marked degree the species of hypochondriasis to which the subjects 
of disease of the hair seem specially prone. Through the kindness 
of Dr. Duhring, the author had the opportunity of privately exam- 
ining under the microscope some specimens of these hairs, the 

1 Amer. Journ. of the Med. Sci., July, 1878. 



ATROPHIA PILORUM PROPRIA 



441 



Pig. 52. 



appearances of which are admirably portrayed in the woodcut which 
illustrates his paper. This disorder is not induced by a parasite. 

In the year 1887, a gen- 
tleman applied to the author 
for advice who was in a fair 
condition of general health, 
but the hairs of whose beard, 
when closely examined, both 
with the naked eye and 
the microscope, presented 
a striking resemblance to 
those described and figured 
by Duhring. Microphoto- 
graphs of specimens of these 
hairs show clearly that in 
every case the fission of 
the filament extended com- 
pletely to the base of the 
follicle and produced local 
irritation there. The hairs 
Over several square inches of 
surface were thus uniformly 
affected, normal filaments 
being in such areas absent. 
The interfollicular spaces, 
however, seemed to be ab- 
normally widened, as though 
in these areas such normal 
hairs might have fallen in 
consequence of a species of 
alopecia. The peculiar ap- 
pearance of the beard to 
the naked eye was striking. 
The disease was much more 
strongly marked on the chin 
than on the cheeks or upper 
lip. The curling of some of 
the splinters was complete 
and characteristic. 

Trichorexis Nodosa, 

first described by Wilks 
and Beigel, is a condition 
in which the hairs display 
nodose swellings along the shaft at irregular distances, the beard and 
moustache being, most often affected, though rarely there is involve- 
ment also of the hairs of the scalp. Sherwell, 1 in this country, has 




Trichorexis 



. (After Sohwimmer.) 



Arch, of Derm., July, 1879. 



442 DISEASES OF THE SKIN 

described one such case. The hairs are brittle; and fracture usually 
occurs through the node, leaving a broom-like mass of filaments 
projecting there, while the interuodular portions of the shaft appear 
normal save for some enlargement of the medulla. The fragility of 
the hair ;u the centre of the node, seems to depend upon the tension 
ami consequent fissure of the cortical layer which is greatest at that 
point. No parasite has been discovered in hairs thus affected, their 
bulbs, moreover, being firmly adherent in their follicles. Little is 
known as regards appropriate treatment of the disease, which is, it 
must be said, persistent and disfiguring. Shaving has been followed 
in some of Kaposi's cases by good results; while Roeser 1 advocates 
the local employment of dilute tincture of cantharides. 

Smith, 2 of Dublin, has also reported a curious Case of Nodose 
Swellings of the shafts of the hairs, differing somewhat from those 
described above. Through the kindness of Dr. Duhring, the author 
has been enabled to exhibit some of these hairs in Chicago, micro- 
photographs of which were, at his suggestion, taken by Dr. Belfield, 
of Chicago. Here there was no fragility at the nodes, which com- 
mencing near the scalp were quite regularly displayed along the shaft, 
the fracture being always interuodular. The spherical swellings along 
the shaft were also pigmented in a brown hue, and these contrasting 
with the non-pigmented color of the unaffected portions of the shaft, 
gave the hairs a singularly " checkered" appearance. No parasite was 
discernible in any of the specimens. 

Michelson, under the title " Expansions and Fissures of the 
Hairs," discusses together these and other abnormalities of the pilary 
system and concludes as to the most of them, that they are not 
separate diseases but expressions of an abnormal dryness and brittle- 
ness of the hair due to atrophy. Cases of broom-like Assuring and 
division of the shaft into larger longitudinal splinters, he regards as 
equivalent processes both beginning by a cuticular loss and often 
merging into each other. 

This view may be sound with regard to a number of these rare 
affections ; but even a superficial examination of the longitudinal 
splinters shown in Duhring's and my cases, reveals the fact that the 
shaft represented by the sum of all its splinters, is greater than that 
of the average hair in diameter and circumference. Even the naked 
eye can recognize this fact. The epilating forceps seizing a single 
hair in the case of the author's patient, was distended as in the grasp- 
ing of as many sound filaments as are represented by splinters. 

The therapy of these cases is not well determined. Michelson 
believes shaving to be useless and recommends systematic shampoo- 
ing and oiling — the process pursued in the cases treated by the 
author. Arsenic internally is worth trying in all cases where it is 
not contraindicated. 



1 Annal. de Dorm, et de Syph , 1877-78, pp. 18.% et seq. 

2 Brit. Med. Journ., May 1, 1880. 



ATROPHIA UNGUIS. 443 

Piedra. 

is described as still another condition of the hairs in which dense 
node-like masses are attached to or surround the hair shaft. Morris 
describes these as containing masses of spores. In a single case, 
that of a young girl sent to him by Dr. Holmes, of the Eye and 
Ear Infirmary, the author discovered there were numerous, jet- 
black, horny, and dense spherical masses attached to the hairs of the 
eyelashes of each lid of both eyes. The author was unfortunately 
prevented from securing some of those hairs for microscopical exami- 
nation. 



3. Of Nail. 

Atrophia Unguis. 

Atrophy of the nails may be a congenital or acquired condition, in 
which there is deficient or defective production of the nail substance. 
The congenital forms are usually observed when the digits are poorly 
developed, and there is at the same time a deficiency of the pilary 
growth. The nails may be entirely absent in these cases or merely 
tardy of evolution ; occasionally they are seen, especially upon rudi- 
mentary or coalesced digits, in defective and distorted shapes. 

In acquired atrophy, the nail may be changed either in color, bulk, 
elasticity, firmness, shape, or position. Thus the nail may be 
expanded and thin, narrow and acuminate, friable, furrowed, lami- 
nated, ridged, or otherwise distorted. It may be uniformly or 
partially lustreless, or singularly striped, or even speckled irregularly. 

These changes in various combinations result from traumatism 
chiefly, such injuries, for example, as are common to the toes in the 
boot or shoe, and to the fingers when actively employed in the trades. 
Excessive heat and cold, and constant maceration in chemicals (as 
among photographers, dyers, and druggists) often operate injuriously 
upon the nail tissue. All serious disturbances of systemic nutrition, 
such as are incident to prolonged fevers, surgical accidents, tubercu- 
losis, ataxic conditions, etc., interfere visibly with the nutrition and 
development of the nail. The syphilitic changes in the nail are 
commonly due to gummatous involvement of the matrix. Severe 
ulceration of the matrix is often followed by atrophic or other 
distorted conditions of the nail-substance. 

The treatment of these conditions is largely that of the disorders 
upon which they depend. The nails may often with advantage be 
soaked in unguents, scraped to a desired smoothness, well trimmed, 
and then protected by wax, leather stalls, etc., from injurious con- 
tacts. Arsenic internally is said to be useful in some affections of 
this kind. 



444 DISEASES OF THE SKIN 



4. Of Cutis. 
Atrophia Cutis. 

Gr. a, privitive ; and rpodi/, nutrition. 

Atrophy of the skin is an idiopathic or symptomatic, diffuse or partial, dimin- 
ution of the mass of the integument, or its reduction in size after loss or 
degeneration of one or more of its histological elements. 

The skin and its appendages, in common with other organs of the 
body, may suffer from atrophy, either idiopathic or symptomatic in 
character, and general or partial in extent. It may result from either 
quantitative or qualitative, retrogressive changes, losing thus its 
m-rmal dimensions, either from wasting of one or all of its normal 
elements, or from degenerative changes in the latter, or from their 
complete and final disappearance. Xaturally these changes may be 
simultaneous. They are usually effected slowly, and the results are 
persistent. They are frequent concomitants of a long list of other 
pathological alterations. Usually, however, they succeed the latter. 
Under the general title of atrophy of the skin, several rare forms of 
the disease have been considered. 

Atrophia Senilis. 

This is the frequently recognized cutaneous degeneration peculiar 
to old age. The skin becomes colored in various shades of brown, 
either uniformly or in tolerably distinct maculations over the face, 
dorsum of the hands, the genitalia and the anus, and the lower 
extremities. It is seamed with furrows and wrinkles, often in various 
degrees desquamates slightly, and, losing the cushion of fat upon 
which it rested in earlier life, is either readily raised from the sub- 
cutaneous structures, or depends from them in loose folds. Pea- to 
finger-nail sized, verruciform, dirty-yellowish accumulations of epi- 
dermis become visible, often in numbers on the face and elsewhere, 
extending either as far as the deeper portions of the horny layer or 
the rete. 

The cutaneous atrophy in such cases may be characterized by 
unusual dryness, with failure of reproduction of the elements of the 
skin after the loss by physiological waste. The epidermis and derma, 
by their shrivelling, lose largely their characteristic interdigitations, 
while the elements of which they are composed are impoverished in 
protoplasm. Vessels, relatively numerous before, disappear ; pigment 
multiplies; the hairs are either produced as lanugo filaments, or fall 
as the papillae in the fundus of their sacs flatten ; the root-sheaths 
encroach upon the follicle; while the sebaceous and coil-glands may 
either disappear, or dilate and become filled with an epidermic detritus. 

In other cases the skin elements undergo a true metamorjjhosis, 
fatty, lardaceous, amyloid, colloid, waxy, or vitreous. 



ATROPHIA CUTIS. 445 

Atrophia Maculosa et Striata. 

Partial idiopathic atrophy of the skin occurs most frequently in 
linear cicatriform striae or streaks, an inch or more in length, 
developed chiefly about the hips, buttocks, and upper portion of the 
thighs in both sexes of adult years. Less frequently they are observed 
upon the neck, trunk, and extremities. They are insidious of devel- 
opment, indelibly persistent, and appear as sensibly thinned, glisten- 
ing, and often depressed lines or furrows, having a whitish hue, with 
an occasional blending of a very delicate purplish tint. They are 
usually multiple, and at times abundantly displayed, running in 
various curves, for the most part parallel with the long axis of the 
body. They occasion no subjective sensation and their etiology is 
unknown. 

Much more rarely the atrophic areas occur in macular patches. 
The lesions are then fewer, more isolated, and are discovered more 
frequently upon the extremities, but also on the trunk, varyiug in 
size from a cotfee-bean to a chestnut. This form of atrophy often 
succeeds either an erythematous or pigmented condition, which very 
slowly changes till there is formed the dead white, round or oval, often 
insensitive patch, resembling coarsely a vaccine cicatrix. Taylor, 1 
and Atkinson, 2 have described some very interesting features in this 
process; and the author has been able to verify the accuracy of their 
observations in two typical cases of the affection he has had the oppor- 
tunity of studying. In both, the lesions occurred about the ankles of 
women with menstrual derangements, the largest spot of all attaining 
the size of the transverse section of a hen's egg. The patches were 
in various degrees insensitive, very slightly depressed, smooth, glis- 
tening, and scar-like, the condition being the sequel of brown to 
chocolate tinted pigmentations, limited to the spaces which become 
afterward atrophic, Cantani 3 describes similar atrophic maculae, 
where there had been a bluish-red color, evidently due to the 
development of minute vascular capillaries. The sensibility of the 
skin was unaltered. Under the microscope both the linear and 
macular lesions show separation of the fibrous fasciculi, effacement of 
the papillary layer of the corium, and diminution in the number of 
vessels and glandular appendages. In Taylor's and the author's cases, 
the maculae were quite hairless; in Atkinson's, the hairs were rela- 
tively few in number. 

Fere' and Quemonne 4 have also described two singular cases observed 
in Charcot's clinic. In one of these, minute, whitish, elongated 
cicatrices appeared, about which there was marked pigmentation of 
the skin. They were abundant in the lumbar region. In a second 
case, brownish lines"appeared over the breast of an unmarried woman, 
which gradually grew paler, while others appeared over the skin of 
the throat. Those wmich were recent had a brownish or bluish-red 
color; others were of a dead white hue; some appeared over the 

1 Archives of Dermatology, vol. ii. No. 2, 1867. 2 Rich, and Lou. Med Journ., Nov. 16, 1877. 

3 11 Morgagni, May, 1881. * Le Progres Med., Oct. 29, 1881, p. 837. 



446 DISEASES OF THE SKIN. 

lumbar region and the upper part of the buttocks; but there was 
none over the belly, groins, and the thighs. In both cases the 
regions attacked were those in which there was no suspicion that the 
vergeturcs resulted from overdistention of the skin. 

These lesions are to be distinguished from the sequelae of morpheea, 
syphilis, and other diseases capable of leaving atrophic areas. A 
previous history of such pathological conditions would usually be 
needful; but in the cases where there is precedent telangiectasis, 
hyperemia, or marked pigmentation of the spot, the diagnosis from 
morphooa will be, as several authors suggest, attended with some 
difficulty. 

Partial symptomatic atrophy of the skin, in its simplest form, 
results from the traumatic action of tumors (ovarian, uterine, mesen- 
teric, etc.), by which it is distended. The well-known results of 
a first pregnancy conducted to full term, are linear atrophies, at first 
of a violet tint, and later of a dead whitish hue, which are indis- 
tinguishable, both clinically and pathologically, from the idiopathic 
lesions of similar aspect. Partial symptomatic atrophy, with degen- 
eration of the cutaneous elements (fatty, lardaceous, waxy, etc.), is the 
sequel common to a long list of cutaneous affections. 

Blanching Atrophy of the Skin. — Several instances of this 
peculiar degeneration of the integument have been observed. It is 
characterized by an unnatural whiteness or pallor of the surface, with 
considerable tension and teuuity of the epidermis, usually limited to 
the extremities (the arms and palmar faces, and the thighs and legs 
and plantar faces); moderate exfoliation occurs, and the latter, in 
connection with the tension to which the skin is subjected, is respon- 
sible for more or less painful subjective sensations. The disorder is 
chronic in its course, aud may originate in infancy. 

This condition is occasionally illustrated by patients affected with 
a sensori-motor paralysis of one limb, when the muscles waste aud 
the fat-cells persist, multiply, or wholly disappear. The skin of such 
limbs, wholly or in patches, becomes unnaturally soft and delicate, and 
undergoes a loss of pigment and hairs at the same time that its bulk 
actually diminishes. The nails may participate in the process. In 
yet other cases of trophic disturbance, the skin shrivels and assumes 
instead of a whitish, a yellowish, or yellowish-gray tinge. 

"Glossy Fingers." — The "glossy fingers"' described by Sir 
James Paget, are probably of the same general character. They are 
"tapering, smooth, hairless, unwrinkled, glossy, pink, and ruddy, or 
blotched, as if with permanent chilblains." One or several fingers 
are affected. The condition is associated with neuralgia or nervous 
impairment. The relations of this and several symmetrical disorders 
of the hands and feet to the so-called " perforating ulcer of the foot," 
"asphyxia" of the extremities, "symmetrical gangrene" of the 
extremities, and so-called "dying of the fingers," all manifestly 
trophoneurotic affections (see the chapter on this subject), have not 
yet been satisfactorily%established. 



KELOID. 447 



CLASS YI. 

NEW GKOWTHS. 

1. Of Connective Tissue. 
Keloid. 

Gr. xn^fi, a crab's claw. 

Keloid is a benign cutaneous neoplasm, occurring as one or more elevated, 
whitish and reddish, firm and elastic nodules, plaques, ridges, or radiating 
strise ; or as several of such forms in combination, resembling an hyper- 
trophied cicatrix. 

The term Keloid, first given to this disease by Alibert, should be 
restricted to it exclusively. It has also been termed Cheloid, Kelis, 
and Cancroid. The so-called Keloid of Addison, is known to-day 
more properly as scleroderma. 

Authors have described two varieties of this disease: first, the 
"true," "spontaneous," idiopathic form ; second, the "false," "spu- 
rious," or cicatricial. In these pages the first described condition is 
alone considered as entitled to the name Keloid. The so-called 
spurious form of the aifection is described in the pages devoted to 
Cicatrix. 

Symptoms. — The new-formation of this disease is always of spon- 
taneous origin, never resulting from attempts at repair of ulcerative, 
traumatic, or other losses of tissue. Dense, generally elastic nodules 
are seen embedded in the corium, or projecting above the level of the 
skin and firmly attached to it. They are usually very slow of 
evolution, and, having once obtained their full development and 
assumed one of the several shapes which they affect, usually persist 
for a lifetime. These forms are globular or semi-globular, whitish 
or reddish nodules, buttons, or plaques, with roundish or ovoid out- 
line; linear elevated striae, bands, ridges resembling cords, ribbons, 
or tapes, in irregular outline and disposition ; or combinations of two 
or more of these figures. A common form over the sternum, and in 
other situations where the development of the growth in every direc- 
tion is impeded, is that of a larger central mass with two or more 
diminishing and declining prolongations bearing a remote resemblance 
to the body and claws of a crab. The lesions vary in size from a 
small pea to a large saucer, the largest including the outlying points 
of the limbs or radiating ridges. Over it the skin is reddish or 
whitish in color, smooth, hairless, and occasionally hyper-sensitive to 
pressure and heat. The growth is also at times the seat of sponta- 
neous pain. 



448 



DISEASES OF THE SKIN. 



The most frequent site of the disease is the anterior surface of the 
chest, but it is observed also upon the face, neck, ears, breast, hands, 
between the scapulas, and on the extremities. It may be encoun- 
tered, indeed, upon any portion of the body. I have seen it upon 
the penis of the negro. It is far more common in the colored than 
in the white races. Though frequently multiple, there are rarely 
more than a score of these growths visible at one time upon the skin 
of one person. 

Fig. 53. 




Etiology. — The origin of the disease is exceedingly obscure. Neither 
age, sex, nor previous disorder of the skin seems to have any bearing 
upon its production. It is seen in remarkably vigorous persons 
(more often decidedly in the negro race), but also upou those who are 
weakly. The very young and very old are more rarely affected. 

Pathology. — No little confusion has occurred in consequence of the 
failure to distinguish clearly between keloid and cicatrix. Epithe- 
lioma, sarcoma, fibroma, and other diseases have existed with or 
complicated keloid, and the anatomical features of the last-named 
disorder been thus obscured. 

In true keloid, the papillary layer of the corium and the inter- 
papillary projections of the rete downward are intact. The new 
formation is strictly limited to the middle and lower portions of the 
corium, where whitish, tendinous fibres of connective tissue, dis- 
persed for the most part parallel to the surface of the rete, are 



CICATRIX. 449 

numerous. Lymph-vessels, with proliferated endothelium, com- 
pressed by lougitudinal growth of the fibres, pass in both vertical 
and horizontal planes, for the most part remaining patulous. There 
are few spindle cells and nucleated cells. Many of the blood-vascular 
channels are choked or absent. 

Diagnosis. — The clinical distinction between keloid and cicatrix 
rests mainly upon the history of the lesion whether, that is, it be of 
spontaneous origin, or has resulted from previous disease or traum- 
atism. The situation of the lesions of the former, often over the 
sternum, the infrequeucy of multiple tumors, its claw-like prolonga- 
tions, and yellowish-white, reddish, or grayish-white color, all point 
to the nature of the disease. 

Treatment — Removal of keloid by cauterization and excision is 
not to be practised, as the growth does not fail to reappear. Vidal 
has successfully employed multiple linear scarifications. Various 
stimulating applications may also be made with a view to promote 
resorption, such as the spirit of green soap, iodated glycerine, iodine 
in ointment and tincture, and mercurial and lead plasters. Where 
there is pain, anodyne unguents may be employed topically, such as 
the freshly prepared belladonna plaster, or the ointments of bella- 
donna, stramonium, and opium. By far the most elegant of these, and 
one which also is capable of producing an alterative effect, is the 
oleate of mercury and morphia, manufactured by Squibb, of Brooklyn. 

Internally, quinine, strychnine, arsenic, and the iodide of potas- 
sium have been exhibited with varying success. The author has 
never happened to see a case where internal medication had been 
followed by appreciable results in the diminution of the growth. 

Prognosis. — As regards the general condition of the patient, the 
prognosis is favorable. Very rarely there is spontaneous resorption 
of the nodule or tumor. Generally the latter may be expected to 
persist, after full evolution is attained, for an indefinite period of time. 

Cicatrix. 

Cicatrix is a dense, smooth, whitish or reddish new-formation of the skin, 
occurring where there has been a loss of connective tissue following trau- 
matism or tissue degeneration. 

A cicatrix, as has already been shown, is a new formation of the 
skin, replacing connective tissue which has been lost by traumatism, 
by ulceration, or by some other pathological process. The most of 
cicatrices, as, for example, those following the ulcerations of syphilis, 
the operations of the surgeon, or the dermatitis produced by a severe 
burn, are repai-ative in their effect. 

They vary greatly in shape, size, color, and other characteristics. 
They may be smooth, glossy, shining, scaling, dull-whitish in color, 
or pinkish from vascularization of the surface. They may be linear, 
fan-shaped, circular, corded, ridged, dotted, crateriform, or tumor- 
like. They may be raised above the skin, on a level with it, or de- 
pressed below it. They may be deeply attached to periosteum or 

29 



450 DISEASES OF THE SKIN. 

bone, or be readily movable over the panniculus adiposus. They 
are of deeper color when young, and increase in whiteness with age. 
They arc unprovided, as a rule, with hairs, or coil- or sebaceous glands. 

The most insignificant cicatrices are those resulting from clean, 
incised, and punctured wounds and lesions of similar grade. Here the 
wounded surface furnishes a connective tissue that seals up the solu- 
tion of continuity. Healing is then said to be by " first intention," and 
is at an end, so far as regards the gross appearances, in one to two days. 

Healing by " second intention" occurs alter a longer period in 
solutions of continuity of greater extent, and in those of the same 
extent in aseptic conditions. Here also newly formed connective 
tissue concludes the successive transformations from epithelium and 
leucocytes to embryonal vessels, pus, plasma, and cicatrix. 

Certain peculiarities of cicatrix are seen in special disorders where 
they are produced. The circular, oval, reniform, horse-shoe-shaped, 
S-shaped, and figure-of-eight-shaped scars, thin and flexible, are 
characteristic of syphilis. The cicatrices of variola, zona, and 
ecthyma are slightly different each from the other, though all are of 
small size and depressed. Those of lupus, scrofulosis, and derma- 
titis calorica of severe grade are exceedingly irregular and often 
corded. Hypertrophy of cicatrices is the condition already described 
as spurious or false keloid. Here the resemblance to true keloid is 
produced by a tumor-like development of the cicatrix, forming a 
ridge, button, knob, indurated fold, or puckered and irregularly 
circumscribed whitish or reddish lesion. 

These have been described as following almost every traumatism 
and destructive process to which the integument is liable. 

A case of cicatrix undergoing involution, has been described by 
Dyce Duckworth, in a man aged fifty, who suffered from rheumatic 
fever, on two occasions, ten years before the date of report. He had 
pericarditis, and was blistered over the prrecordia. Nine months 
afterward, lines of cicatricial growth began to form in the scar left 
by the blister, and they extended rapidly. In two years' time they 
were still enlarging. In seven years, some subsidence was noticed, 
and, when exhibited ten years after their first formation, involution 
was markedly progressing. The case illustrates the frequent origin 
of scar tissue, its common occurrence over the sternum, and the fact 
of the subsidence of the new growth in the course of time. 1 

Clulton 2 reports a case of cicatrix following erasion of a lupous 
patch, an issue which may be regarded as the most fortunate for any 
case. 

Purdon 3 announces the same result following a psoriasis treated with 
green soap ; and Taylor 4 reports the same as a rare result of syphilis. 

Keloid-like cicatrix of the cheeks, is far from uncommon following 
acne. Its lesion is usually smoothed down in the process of time, 
after the disappearance of the sebaceous gland disorder, till the 
deformity is greatly lessened, and often scarcely noticeable. 

i lirit. Med. Journ., October 8, 1881, p. 597. - Ibid., January 20, 1883. 

3 Journ. of Cutan. and Vener. Dis., 1883, p. 203. * Ibid., 1883, p. 308. 



CICATRIX- 451 

Etiology. — The formation of a cicatrix is always preceded by a 
traumatism or pathological loss of tissue, the remote causes of which 
have the widest possible variation. Hypertrophied cicatrix, or 
spurious keloid, is always developed from a simple scar. It affects 
persons of all ages and sexes, but with decided preference for the 
negro race. The traumatism may occur from piercing the ears for 
ear-rings, the operations of surgery, leech-bites, the deeper burns 
from fire, and wounds inflicted by accident. It often follows cutting 
the hands with glass ; and has been caused by the spur of a cock. 
It is sufficiently common after the occurrence of acne indurata, but 
the latter is of all its forms the least persistent. In general, it may 
be concluded, however, that it occurs chiefly in those whose skins 
have a special tendency to such development. 

Pathology. — Kaposi has demonstrated a difference, rather of dispo- 
sition than of kind, between keloid, hypertrophied cicatrix, and 
" cicatricial keloid." In the first, the epidermis is described as 
intact, while the corium at one level exhibits whitish, thickened, and 
closely packed bundles of fibrous elements, lying parallel to the long 
axis of the tumor and the surface of the skin, traversed here and 
there diagonally by similar bundles, all probably derived originally 
from the sheaths of the bloodvessels. In the second, the papillary 
layer of the corium has been destroyed by the process of which the 
cicatrix is a resultant, and the latter does not surpass its original 
limits by invading the unaltered peripheral tissues. The connective- 
tissue bundles are here also much less closely aggregated. In the 
third, the two forms described above can be seen combined, the 
papillary layer being destroyed, and the peripheral parts invaded by 
the connective-tissue new growth. 

Diagnosis. — The distinction between hypertrophied cicatrix and 
keloid is based upon the fact, chiefly clinical, that the last named is 
a spontaneous affection and the former is always the result of a trau- 
matic or pathological loss of tissue. 

In any doubtful case a distinction between hypertrophied cicatrix 
and keloid would be needless from a practical point of view. Fol- 
lowing the piercing of the lobule of the ear for the insertion of ear- 
rings, the lesion is distinguishable by pinching the part between the 
fingers, when a globular, pea- to cherry-sized mass will be felt firmly 
embedded in the derma between the reflected folds of the integu- 
ment. Upon the face, after the occurrence of acne, it can be usually 
seen as a puckered ridge, often transverse in direction, occupying the 
region of the cheek. 

Treatment. — The resources of modern surgery are to be trusted in 
the production of laudable cicatrices when all antiseptic precautions 
are observed. The treatment of pathological conditions likely to be 
followed by cicatrices, is the treatment largely of the special disease 
in which such loss of tissue occurs, e. g., the ulcer left by a degener- 
ating syphilitic gumma of the skin. 

The treatment of hypertrophied cicatrix, or false keloid, is the 
treatment of keloid already given. 



452 



DISEASES OF THE SKIN 



Fibroma. 

Lat fibra, a fibre. 

Fibromata arc cutaneous or subcutaneous neoplastic tumors, projecting in dif- 
ferent degrees from the surface, single or multiple, of several grades of 
density, distinctly circumscribed, covered either by a sound and attached, or 
rarely by an ulcerated integument, and varying in size from a small pea to 
a foetal head. 
Symptoms. — Fibroma is a disease characterized usually by the 

occurrence of numerous roundish, sottish, semi-solid, or solid growths, 



Pro. .".i 



Pio. 55. 








/ 




Multiple fibromata. (Gross.) 







Large single fibroma. (From a photograph 
of one of the author's patients.) 



varying in size from that of a small pea to tumors of several pounds 
weight, though more rarely the neoplasm is single. They are often 



FlhROMA. 453 

called molluscous fibromata, as the disease was termed at one time 
molluscum fibrosum. When quite small they are seated within or 
beneath the skin, where they can be distinguished as distinctly cir- 
cumscribed nodules, buttons, or plaques often slightly projecting. 
When more fully developed they become sessile, pedunculated, or 
largely pendulous tumors, hanging from the part to which they are 
attached so as to resemble in shape a cherry, a nipple, a pear, or a 
sausage. They are commonly covered by an integument which is 
natural in color and suppleness, though the latter may be traversed 
by bloodvessels; sprinkled with comedones or patent orifices of seba- 
ceous gland ducts; thinned or thickened, or in a state of ulceration; 
the last named being usually the result of externally operating causes 
in tumors of large size. They are productive of no subjective sensa- 
tion beyond the more or less uncomfortable tension produced by the 
weight of those attaining a great size. When multiple, they may be 
seen in various degrees of development, covering in hundreds the 
entire body, especially the scalp, face, trunk, genitals, and extremities. 
Upon the lids, they may interfere with vision by the production of 
ptosis. To the touch they may be felt as softish, somewhat elastic, 
firm, or lobulated masses, though at times nothing but a double fold 
of skin can be perceived, or a cord-like contained body. 

They are often congenital. When closely set together upon the 
skin, and of small size and pendulous, the features of the disease 
are characteristic. 

Schwimmer distinguishes between these lesions, usually congenital 
(termed by him, soft fibroma), and the dense tumors of similar 
anatomical features (termed by him, firm or hard fibromas). The 
latter are circumscribed, deeply seated, very slow of development, 
and apt to induce changes in the tissues which surround them. They 
may undergo fatty degeneration, or ossification, or calcification. 

Dr. R. W. Taylor, of New York, 1 in an interesting paper on the 
mode of development and course of fibroma, and its relations to 
acrochordon and other cutaneous offshoots, describes the first appear- 
ance of the disease as a roundish spot over which the skin is uplifted. 
It is of a light pinkish color. The tumor is soft and suggests to the 
touch a thinning of the derma beneath it. By firm pressure over 
such lesions when they have in size attained about half an inch in 
diameter, they may be slowly pushed downward into the skin, and 
the sensation is produced to the touch, of a foramen in the derma. 
Fusion between the new growth and the skin over it, is of early 
occurrence. The roundish or oval form of the tumor depends upon 
the direction of the bundles of the subcutaneous tissues of the part 
invaded. After reaching full development, it may be replaced by 
warty growths, pouches, or nipples. Involution is more common 
when the patient is under thirty years of age. Derrnatolysis is pro- 
duced by great activity of the growth of one, or fusion of several 
tumors, by which a flap of skin is formed. 

1 Journ. of Cutan. and Gemto-tJrinary Dis., Feb 1S87. 



454 DISEASES OF THE SKIN. 

The large tumors in the skin of the patient carefully studied by 
Taylor, suggested, when handled, that they contained boiled vermi- 
celli, or a Dumber of thread-worms, and contrasted thus with the 
firm or semi-solid lesions of older patients affected with fibroma. 
The soft and gelatinous quality of the neoplasm in earlier life is 
believed to be proportioned to the age of the subject, and this rapid 
development and sueculency of structure are the only conditions of a 
perfect involution -which are not to be looked for in the firmer, more 
slowly growing fibromata of later years. 

When involution occurs, after full maturity of the lesions has been 
attained, the softish contents of the tumors are adherent to the cutis 
above, and the cutaneous atrophy is proportioned to the rapidity of 
development of the growth and the firmness of its structure. Then 
comes a purse-like pedunculation of the tumor, produced by encroach- 
ment of the skin upon its pedicle, rendering its invagination, sup- 
posably possible before, afterward difficult or impossible. Then 
gradually the neoplasm loses its skin-connection. Eventually, in 
many cases only fibrous cords are left, evidently attached to the con- 
nective tissue beneath, the skiu color paling as the vascular tension 
correspondingly diminishes. Soon the dermal foramen closes, and 
the involution process is at an end. Then empty and wrinkled 
pouches or purses of integument are left, wdiose further shrinking 
produces multiple warty or nipple-like elevations of tissue (under the 
microscope recognized as fibrous structures with epithelial envelope), 
much in color like the virgin-nipple, or the scrotum of a boy. From 
four months to a year was requisite for the mature development of 
the tumors, and nearly as long a period for the completion of the 
process of involution. The dermatolytic flap was permanent. Dr. 
Taylor believes, as a result of his interesting study, that there is the 
closest possible relation between fibroma, and the verrucous growths 
called acrochordon and ecphyma mollusciforme. 

Etiology. — The disease is peculiar to neither sex ; and, though 
observed in adults, is commonly first developed in childhood. It 
cannot be claimed as peculiar to any race, though in this country the 
negroes have probably furnished the largest field for its .observation. 
Hebra called attention to the low standard of physical and mental 
development of the subjects of the disease seen by him, a fact well illus- 
trated in a case recently presented at the author's clinic, the patient 
being an exceedingly myopic, poorly nourished, white, male dwarf, 
whose body was literally covered with fibromata from the scalp to 
the feet. In view of this well established clinical fact, the heredita- 
bility of the disease, which is rendered probable by recorded observa- 
tions, seems capable of explanation. It has been noted in three 
successive generations and in several children of one family. The 
precise cause of the disease is unknown. It is, however, reasonable 
to conclude that it is due to a vice of local development under the 
influence of a constitutional predisposition. 

Pathology. — Fibromata originate in gelatinous connective-tissue 
elements, which undergo metamorphosis into bundles of fibres, the 



FIBROMA. 455 

tumors always exhibiting more of the formed material in the outer, 
and the formative or protoplasmic material in the central parts of the 
mass. The fibrous bundles pass downward, and unite with those of 
the derma or subcutaneous tissue, forming thus a firm attachment for 
the pedicle of all pedunculated tumors. There is some question as to 
whether these growths originate in the deep interspaces of the corium, 
or in the connective tissue about the hair-follicles or fat lobules. 

Heitzmann 1 divides the fibrous tumors of the skin into two classes : 
" a. Dense, fibrous, connective-tissue bundles with relatively few 
spindle-shaped protoplasmic bodies or solid nuclei running in all 
directions, apparently without any regularity, thus producing a hard 
and dense felt-like tissue. This is an imitation of the structure of 
aponeui'oses or interarticular ligaments, if scantily supplied with 
bloodvessels ; or of periosteum and perichondrium, if holding a larger 
number of bloodvessels, b. Dense, fibrous, connective-tissue bundles, 
holding in their meshes a jelly-like basis substance, with a small 
number of protoplasmic bodies. This variety is an imitation of the 
structure met with in the valves of the heart mainly upou their inser- 
tions. The supply of bloodvessels, as a rule, is scanty. Both 
varieties are common tumors of the skin, in the shape of hard, sessile 
nodules and nodes (hard fibroma); or tumors of greatly varying size 
but softer consistence (soft or myxo-fibroma) ; or shallow, as a rule 
pigmeuted, elevations of the skin (npevi); or scar-like, irregularly 
branching, sometimes freely vascularized new formations (keloid)." 

A very large number of fibromata are of the so-called "mixed" 
variety. Some spring from the nerve-sheaths, and actually contain 
nervous filaments (neuro-fibroma) ; others from muscular, vascular, 
and glandular tissues, the compound tumor receiving in this way a 
part of its constituent elements ; often warty growths form with par- 
ticipation of epithelium in the connective tissue, constituting thus an 
epithelioma (so-galled " papilloma"). The large pendulous tumors of 
nsevus lipomatodes may be examples of mixed fibromata whose surface 
is composed of pigmented and hairy skin. 

Diagnosis. — The tumors of molluscum fibrosum are to be distin- 
guished clinically from multiple cutaneous sarcomata, by the viola- 
ceous or reddish color of the latter, their absence of pedunculation, 
their greater tendency to ulceration, and their evidently malignant 
character. From the tubercles of lepra they are differentiated by the 
entire absence of constitutional impairment and their general develop- 
ment in far greater multiplicity. The tumors of molluscum epithe- 
liale differ in their contents, superficial location, and in the frequent 
presence of the dark punctum at their summits. 

Neuroma is usually painful ; lipoma less frequently multiple and 
pedunculated, and more suggestive, when handled, of the "pillowy" 
sensation to the touch. Warty growths are readily distinguished by 
their vegetating summits ; and the gummata of syphilis, by the con- 
comitant or prior symptoms of the existence of lues. 

l Archiv. of Dermat., October, 1880, p. 378 



45b' DISEASES OF THE SKIN. 

Treatment. — The treatment of large single fibromata is surgical; 
involving the employment of knife, ligature, ecraseur, or galvano- 
or thermo-cauterization. Multiple lesions are often so numerous as 
to forbid such interference. When there is a distinct vice of develop- 
ment or inherited tendency to the disease, little can be accomplished 
in the way of treatment. 

Prognosis. — Rarely, one or more of these lesions disappear by 
spontaneous involution. More commonly they persist after their 
evolution is completed. Marasmus, tuberculosis, and a fatal result 
may occur. One or several of the tumors may become sources of 
danger from the occurrence in them of an active inflammation with 
resulting degeneration and septicemic consequences. The disease, 
however, does not, in many cases, shorten life. In general, the prog- 
nosis of multiple fibromata may be regarded as unfavorable. 

Neuroma. 

Gr. vevpov, nerve. 

Neuroma is a disease characterized by the occurrence of single or multiple, 
pin-head to small nut-sized, usually painful cutaneous papules or tubercles, 
constituted of a new growth of connective tissue and non-medullated nerves. 

Symptoms. — But few cases of this rare disease are recorded. The 
description appended is a summary of the symptoms detailed in the 
reports of Duhring, 1 of Rump, 2 and of Kosinski. 3 

The patients were all men of middle life or advanced years, who 
exhibited upon the shoulders, arms, thighs, or buttocks, numerous 
disseminated and defined, pin-head to hazel-nut sized, roundish or 
oval nodules or tubercles. They were either painful, or painless at 
the onset and painful later. In Rump's case, which was a sample of 
the false neuromata of Virchow (fibroid tumors of the nerve), there 
was no pain throughout the course of the disease. 

The nodules were not arranged along the tracts of nerves ; were 
immovable, dense, and elastic ; were fixed in the corium, and extended 
below it. They were purplish to pinkish in color ; and the skin 
between them was unaltered, or like that enveloping the lesions, dry, 
uneven, and desquamative. The tubercles were both tender and 
painful, the pain being excruciating, paroxysmal, usually lasting in 
Duhring's patient for an hour, and radiating. It was aggravated by 
temperature changes, mental emotion, and movement. 

Sections of the growth in Duhring's case showed anatomically a 
connective-tissue stroma, interwoven with fibres for the most part 
lying parallel with one another, each fibre composed of a finely 
granular central substance surrounded by a sheath containing 
numerous, elongated, oval, somewhat granular nuclei. There was 
also yellow elastic tissue, bloodvessels with thickened and nucleated 

1 Case of Painful Neuroma of the Skin, Amer. .Tourri of the Med. Sciences, Ocfober, 187:5 ; also Sup. 
plement to the same, with ruts, Amer. Journ. of the Med. Sciences, October, 1881. 
tArcb. of Path Anat., Bd. Ixxx.. lift 1. 
8 Centralblatt f. Chirm -., 1874, No 16. 



NEUROMA 
Fig. 56. 



457 




external appearance. (Duhw.ng.) 

Fig. 57. 




Microscopic structure of neuroma. (Duhring ) 



458 DISEASES OF THE SKIN. 

walls, and about the latter lymphoid, cell-like bodies. There was 
entire absence of unstriated muscular and fibrillar connective tissue. 
The specimen was certainly unique, representing the true amvelinic 
neuromata of Virchow. \n Kosinski's case, non-medullated nerve 
fibre- and connective tissue were also discovered. In both cases, 
exsection of a portion of nerve (brachial plexus, of the one; and small 
sciatic, of the other) was followed by considerable diminution of pain, 
and almost entire disappearance of the growths. In Rump's case, 
which, as stated above, represented the fibromata and so-called fibro- 
aucleated tumors of Virchow, the nodules were strung upon the 
same nerve, " like beads upon a rosary," and were similarly displayed 
upon its branches. Spinal, cerebral, and sympathetic fibres were all 
involved. 

Duhring, in commenting upon these interesting cases, calls attention 
to the distinction between these purely cutaneous lesions and the 
generally solitary, movable, and " painful subcutaneous tubercle." 

Xanthoma. 

Gr. gavOog, yellow. 

Xanthoma is a cutaneous neoplasm, exhibited in one or several, isolated or 
grouped, occasionally symmetrical, flat or slightly elevated, yellowish ma- 
cules, papules, plaques, or tubercles, which are most commonly situated 
upon the eyelids. 

This affection, also termed Xanthelasma and Vitiligoidea, was first 
described by Raver, 1 and its clinical divisions established bv Addison 
and Gull. 

Symptoms. — The macular symptoms of the disease, are bean- to 
finger-sized plaques, either quite flat or with slightly elevated borders, 
often constituted by an aggregation of millet-seed-sized lesions, and 
covered with an apparently normal integument. In color they vary 
from light and chrome yellow to the "coffee and milk" shade; and 
in shape they may be punctiform, roundish, oval, elongated, or quite 
irregularly grouped. They are distinctly circumscribed, and when 
gathered between the thumb and finger do not produce the sensation 
of the presence of a foreign material. They are most often seen upon 
the eyelids near the inner canthus, where they may be symmetrically 
disposed about the two orbits. But they may invade also the peri- 
orbicular region, as also, rarely, the cheeks, the nose, the ears, and 
the nucha. They are rarely productive of subjective sensation, being 
occasionally the seat of slight pruritus. This is the commoner form 
of the disease, and is termed Xanthoma Planum. 

The tubercular lesions of the same affection, known as Xan- 
thoma Tuberculosum, may coexist with the plane lesions described 
above, and scarcely differ from the latter save in their greater de- 
velopment. They arc whitish or yellowish papules, plaques, and 

1 Traite prat. dee maladies de la Peaii. Paris, 1830. 



Plate II. 




Xanthoma of the FI ands, Elbows, and Knees . 

From a Photograph of one of the author's patients.) 

(to face p. 458.) 



XANTHOMA. 459 

tubercles, circumscribed in contour, covered with an unaltered epi- 
dermis, and determinable by palpation as having greater consistence 
than the flat macules. They are less frequently seen upon the lids, 
but occur upon the scalp, cheeks, palmar and plantar surfaces, the 
genital region, and about the joints of the digits. 

Other exaggerated forms are described. Thus sessile or pedun- 
culated tumors, cutaneous or subcutaneous in their attachment, nut- 
to hen's egg in size, and originating in one or another of the lesions 
named above, are described by Cary 1 and Chambard. 2 To these the 
name Xanthoma Tuberosum should be limited. Xanthoma 
Multiplex is the form in which the lesions, usually first mani- 
fested in the sites of election and in their simplest development, pro- 
ceed to a gradual invasion of the trunk and extremities. Occasion- 
ally the mucous surfaces of the mouth, of the respiratory and 
gastro-intestinal tracts are involved, as also of the surfaces of the 
peritoneum, endocardium, and larger arteries. The genital region, 
palate, oesophagus, spleen, trachea, and cornea have all been recog- 
nized as seats of the disease. 

The conglomerate forms upon the skin constitute large plaques 
resembling tumors, compounded of lesions of xanthoma tuberosum. 
They are distinctly circumscribed, deeply embedded in the corium, 
elevated to the extent of one-fourth to one-half of an inch above the 
general level of the integument, and irregularly furrowed or lobu- 
lated superficially. An illustration of xanthoma occurring in full 
development and in rare situations, is presented in Plate II., taken 
from a photograph of one of the author's cases. 

In a proportion of cases, the disease is accompanied by a gener- 
alized coloration of the skin in a yellowish shade, which has been 
variously interpreted as a xanthomatous dyschromia, and as a true 
icterus. The former is the more probable explanation of the fact, as 
in such cases the urine and viscera have been found normal. 

Korach 3 has described the interesting case of a woman twenty-five 
years old suffering from chronic icterus produced by closure of the 
ductus choledochus. Beside the typical patches of xanthelasma on 
the lids, the skin surface was generally and similarly affected. Thus 
the extensor faces of the extremities, the palms of the hands, nates, 
and other parts were extensively covered with sago-grain to pepper- 
corn sized papules and tubercles of xanthoma, both flat and elevated. 

Etiology. — The causes of the disease are unknown. In many cases 
the lesions are first observed in early childhood, though they are 
encountered also in middle and later life. 

In some cases the disease would seem to be inherited. Hutchinson 
and Church have reported several instances where more than one' 
member of a single family suffered from the disease ; and the mother 
of the patient exhibiting multiple lesions upon the elbows and knees 
selected by the author for illustration, presented plane lesions of xan- 

i Ann. de Derm, et de Syph., 1880, p. 75. 

2 Archiv. de Phys. norm et path., Sept. and Dec, 1879. 

3 Dentsch. med. Wochenschrift, No. 20, 1881. 



460 DISEASES OF THE SJCIX. 

thoma ni'iir the inner canthi of the eyes. The association of xan- 
thoma with disease of the liver, diabetes, rheumatism, and other 
disorders cannot be denied for certain cases. In the majority, no 
such association can be recognized; and careful post-mortem examina- 
tion of patients affected with xanthoma, and dead of intercurrent 
disease, ha- cither demonstrated a normal condition of the liver or a 
disorder of it quite disconnected with xanthoma, such a- a stricture 
of the bile-ducts from cicatricial contraction. In Mr. Malcolm 
Morris's cases, occurring in diabetic subjects, three women and one 
man, the eyelid- were unaffected, and the partially xanthomatous 
lesions transitory in duration. 

The author has reported a single case coming under his observa- 
tion, where multiple plane lesions of the lid in a middle-aged woman 
succeeded a dermatitis of that region, induced by accidental contact 
with a corrosive solution of mercury. 

Dr. Barlow 1 reports one congenital ease of the disease. 

Pathology. — Pathological studies of the affection have been made 
by Cham bard, whose conclusions are briefly these : " The three forms, 
plane, tubercular, and tuberose, are the results of two processes, irri- 
tative and retrogressive; the first prevalent in the tubercular and 
tuberose forms, the last in the plane variety. 

" In xanthoma planum, the irritative process is represented by an 
albuminous tumefaction of the connective-tissue elements, with pro- 
liferation of their nuclei; the retrogressive process, by a fatty de- 
generation of their protoplasm. In the other forms, the irritative 
process is distinguished by the new formation of connective tissue; 
the retrogressive by a fatty infiltration of the old and newly formed 
connective-tissue elements. In both forms, not only the connective 
tissue of the derma, but also the vascular, glandular, and nervous 
organs, within and about the sclerosed nodules, are invaded. The 
sclerotic process involves also the fibrous envelope of the sebaceous 
and sudoriparous glands (periadenitis) ; the internal and external 
sheaths of the vessels (periarteritis, endarteritis obliterans); and the 
lamellar sheath and intrafascicular connective tissue of the nerves 
(perineuritis, endoneuritis). The nervous involvement is thought to 
explain not only the pain, but also the tenderness peculiar to the 
xanthelasmie tubercles." 

Balzer's conclusions as to the parasitic nature of the disease have 
not been verified by Hauot and Eichoff. 2 

In the careful and exhaustive paper by Dr. Karl Toutou 3 it is 
clearly shown that the disease is due to an atypical new formation of 
cells seated in the coriura. These have a sharply defined membrane ; 
and a large, roundish, or ovalish nucleus. All parts are thickly 
studded with fat drops, and it is from these that the yellow coloring 
of the xanthoma plaques is derived. They originate in and near the 
lymph spaces and conduits of the derma ; and in the building up of 

1 Path. Soc. of London, 1884. " Deutscli. med. Wocli., No. 4, 1884. 

:i Vierttjat. f. Derm u. Syph., lift. 1, 1885, p. 3. 



ADENOMA. 461 

the lesions are associated chiefly with connective and yellow elastic 
tissue. The sebaceous glands are not, as was once held by Hebra, Geber, 
and Simon, concerned in the process. The epidermis superimposed 
upon the lesions may be thinned, but is otherwise pathologically 
unaltered. 

Diagnosis. — Milia are occasionally associated upon the lids in the 
form of oval plaques, but are distinguishable from xanthoma by the 
possibility of expressing their contents. 

The diagnosis from all other lesions is readily made, when con- 
sideration is had of the peculiar yellowish or saffron-like hue of 
xanthoma, and the common situation, form, and general character- 
istics of its plane or nodular lesions. 

Treatment. — Erasion and excision are the usual methods of remov- 
ing xanthomata. Care should be taken in such operations to avoid a 
consequent ectropion when the operation is performed upon the skin 
of the eyelids. The Paquelin knife, which I have employed for 
this purpose, is objectionable on account of the radiation of the heat 
to the globe of the eye. With the tumor slipped through an aper- 
ture in a thin sheet of asbestos paper, such as is now found in the 
markets, this inconvenience might be avoided. 

The more modern method, however, of electrolysis is far preferable 
to others. Caustics also have been successfully employed. Besnier 
employs phosphorus internally followed by turpentine, by which 
course the disease is said to have been relieved. Wilson, with the 
same end in view, employed nitro-muriatic acid, arsenic, bitters, and 
blue pill. 

Prognosis. — The lesions, when not removed, are liable to persist 
through life. Spontaneous involution is said to occur very rarely. 
The French authors, who have given considerable attention to this 
subject, are disposed to believe that some cases of xanthoma tubero- 
sum, with permanent xanthochromia and involvement of the inner 
coats of the larger vessels, may prove serious. 

Adenoma. 

Gr. aSijv, a gland. 

Adenoma is a new growth in which there is proliferation of the glandular 
cells and their investing connective tissue, which constitute normally a 
secreting organ of the skin. 

Authors are not generally agreed as to what growths shall and 
what shall not be considered exclusively as adenomata. Geber 
includes under this title adenoma sebaceum, adenoma sudoriferum, 
and epithelioma molluscum. Anderson, on the other hand, gives no 
consideration to the subject, and other authors relegate it to a para- 
graph. This is unquestionably due to the fact that, apart from the 
lesions described in this work as molluscum epitheliale, a number of 
the growths assigned to this class are epitheliomatous. 

1 Deutsch. med. Wochensch. No. 23, 1881. 2 Loc. cit. 



462 DISEASES OF THE SKIN. 

Yet there is no question that true adenomata of unmixed type 
originate from both sebaceous and coil-glands. 

( lertain whitish or yellowish, pin-head-sized, rounded and isolated 
lesions, with gelatinous contents, scattered over the faces of persons 
in middle life and advanced years, are occasionally seen either 
flattened or slightly elevated above the level of the integument. 
They have been described under the title of "colloid degenerations 
of the skin," but are probably instances of adenoma of small acini of 
the sebaceoU9 glands, the epithelium of which has undergone colloid 
degeneration. According to Heitzmann, the distinguishing feature 
of them all is a wreath of cuboidal or short columnar epithelium, 
inclosing a distinct cavity. Besnier, 1 however, concludes that the 
connective-tissue elements of the derma are primarily involved in the 
colloid degeneration, and the glandular epithelia secondarily. 

In general, the features of adenoma are well defined, circumscribed 
tumors, pin-head to small-egg sized and larger, sessile or peduncu- 
lated, softish or quite firm, aud always occurring in regions where 
there are either coil-glands or sebaceous glands. For a time, after 
the formation of such a tumor, the gland or glands from which it is 
proliferated may discharge the usual function. The course of the 
tumor may be stationary; it may atrophy; it may degenerate by an 
ulcerative process; cysts may form ; or the contracted cells undergo 
hyaline, colloid, or fatty degeneration. 

Sections of simple adenomatous tumors always exhibit the epithe- 
lium of the glandular structure from which the new growth was 
derived, and the connective tissue framework of tumors in general. 

The diagnosis is from epithelioma, molluscum epitheliale, steatoina, 
and lipoma, for the exact determination of which examinations of 
sections with the microscope are needful. 

The treatment, when any is required, is surgical ; and the prog- 
nosis, in uncomplicated adenoma, favorable. 



2. Of Muscular Tissue. 
Myoma. 

Gr. /j.vuv, muscle. 

Myoma is a tumor of the skin which is composed in great part of muscular 

fibres. 

Tumors of the skin composed of smooth muscular fibres are 
known as Myomata, Leiomyomata, or Lyomyomata. . But 
little attention had been attracted to these new growths up to a 
recent date. Jullien, 2 however, in a review of the contribution to 
the subject made by Messrs. Brigidi and Marcacci, of Florence, and 

1 Ann. de Derm, et de Svpli , t. x., Nov. 5 and G, 1879. 
"- Ibid., t. iii. 2me s6r., Feb. 25, 18S2. 



MYOMA. 468 

published by them in the Imparziale, in 1881, gives a full capitula- 
tion of the bibliography of the subject. 1 

From these reported cases, it appears that the tumors originate as 
usually single, though occasionally multiple, elevated, disseminated, 
small pin-head to orange-sized, macular or tubercular lesions, the 
skin covering which is smooth, stretched, and glistening, with a rosy 
or dark reddish tint, paliug or not under pressure. The developed 
lesions may be sessile or pedunculated, and either intensely painful, 
pruritic, or remarkably sensitive to cold. Under the influence of 
muscular contractions, there may be, as in the cases of Challand and 
Axel-Key, slow vermicular motion and frequent changes of volume, 
or other evidences of contractility. They occur either as generalized 
lesions, or limited to the thorax, scrotum, mammae, labia majora, and 
the hands and feet, including the palmar and plantar surfaces. The 
ages of the patieuts varied from the twenty-fifth to the sixty-fifth 
year of life. Of thirteen persons whose sex was given, five were 
males and eight females. 

Pathologically, these cases were reported as either pure myomata, 
or highly vascular types of Myoma Telangiectodes and Fibbo- 
myoma. Verneuil's case resembled a neuroma, as it contained not 
only smooth and striated muscular elements and bloodvessels, but 
also nerves. The case of Axel-Key is recorded as one of LYMPH- 
ANGIECTASIA FlBRO-MYOMA. 

The disease is a beuign new growth, and is not to be confounded 
with prurigo, lepra, syphilitic gumma, neuroma, sarcoma, or fibroma. 

Babes, more lately, divides these growths into (a) those derived 
from the smooth muscle-fibres of the vessel- wall ; (6) those derived 
from the cutaneous muscular network. 

The first (angiomyomata) are combinations of new growths of vessels 
with muscle-fibres derived from the vascular parietes. The second 
(dartric myomata) are seen especially about the scrotum, labia, and 
mammae. The deep muscular apparatus of the region named (dartos, 
etc.) contributes in these cases the muscular elements of the tumor. 
In still other cases muscular tumors occur when no such tissue 
normally exists. In these cases a deep aponeurosis or subcutaneous 
muscle furnishes the basis of the neoplasm. 

In a case treated by the author, multiple pin-head to large bean- 
sized congenital tumors were situated near the sterno-cleido-mastoid 
muscle of a girl nineteen years old. These were exquisitely sensitive 
to pressure, were capable of slight vermiform motion when irritated, 
and examination of the largest, after removal, exhibited smooth 
muscular fibres, and, in small proportion, terminal filaments of 
cutaneous nerves. 

The course of the disease is slow, lasting as it may for several 

1 1854, Virchow ; 1858, Forster, Verneuil ; 1864, Klob, two observations; 1871, Challand, two obser- 
vations ; 1873, Mareano Sokoloff; 1878, Axel-Key, Santesson ; 1880, Besnier ; 1881, Arnozan and Vail- 
lard ; Brigidi and Marcacci. 



464 DISEASES OK THE SKIN. 

decades. The etiology is unknown. Treatment is by enucleation ; 
or removal by ligature, electrolysis, or incision. 



3. Of Vessels. 
Angioma. 

(Jr. ayyelov, vessel. 

Angioma is that pathological development which is constituted wholly or in 
part of dilated or new-formed hlood- or lymph-vessels. 

The angiomata are naturally divided into those composed of blood- 
vessels and those formed of lymphatic vessels. The former are much 
more frequent and variable in character. 

Blood-vascular new-growths occur in three forms : naevus vascu- 
losis telangiectasis, and angioma cavernosum. 

Naevus Vasculosus. 

This term is limited to those vascular anomalies of the skin which 
are either visible at birth or become developed in a brief period there- 
after. They commonly occur as irregularly outlined or distinctly 
circumscribed, smooth spots, patches, or maeulations, varying in color 
from light red to 'deep violet and port-wine, either flat or very slightly 
elevated above the general level of the integument. From this type 
wide variations are noted, from the development of pea-sized papules 
or tubercles, to tumors even of large size ; pulsating and aneurysmal 
in character ; spongy or relatively firm ; fading or more rarely per- 
sistent under pressure ; superficial or deeply seated ; venous or arterial 
in their connections ; single or numerous ; and in either case limited 
to a small area or involving a relatively large surface. They are of 
most common occurrence upon the head, but are seen also on the 
trunk and extremities. Often they are the sole lesions of the skin 
present in a single individual ; in other rarer cases they complicate 
moles, warts, and lymphangiomata. 

The surface of these lesions is usually smooth, though it may be 
rugous. They are always compressible, losing their habitual color 
when the blood is forcibly pressed out from the loose mesh-work of 
vessels of which they are composed, and becoming turgid and deeply 
tinted when the blood is forcibly driven into their tissue, as in the 
act of sneezing. 

The course of these lesions varies with their essential character. 
Of the simpler varieties, the larger number increase somewhat in 
extent and development till they have attained a maximum size, and 
then either persist indefinitely or accomplish a species of involution 
after agglutination of the vascular walls, leaving a whitish, cicatri- 
form, occasionally pigmented surface. Others extend indefinitely, 
involving the neighboring mucous surfaces, subcutaneous tissue, and 
deeper structures, forming vast tumors, destructive not only by their 



ANGIOMA. 465 

tendency to extension, but by their mechanical effects. Fortunately, 
these extreme developments are rare. Much more commonly they 
are observed in the forms known as the "port-wine mark" or " claret- 
stain," which awaken no subjective sensations, and are usually of 
clinical importance in consequence of the marked disfigurement which 
they occasion. 

Occasionally, especially in the case of infants but a few days old, 
phagedena or gangrene will suddenly occur in these patches without 
appreciable cause (probably in consequence of the occurrence of 
thrombus), and the entire tumor will be removed, the line of demar- 
cation of the destructive process being exactly limited to the outline 
of the angiomatous tissue. The scar resulting is superficial, and 
becomes smoother in course of time. In this way the author has 
seen spontaneous cure of nsevi of considerable size existing on the 
head and genitalia of infants. 

Telangiectasis. 

Telangiectases are acquired blood-vascular new formations, which 
appear at periods of life other than at birth or a few months later ; 
and are, therefore, distinct from the congenital forms of the disease. 
They are commonly first observed in adult life, and occasionally 
multiply with advancing years. They occur in diffuse and localized 
forms. 

Diffuse, generalized telangiectasis is exceedingly rare. Hillairet 
and Vidal have each observed one such case in individuals of both 
sexes ; the condition being apparently due to systemic disturbance. 

The localized forms are betrayed by the occurrence of flat or 
slightly elevated, pin-head to pea-sized maculse ; diffuse patches ; 
linear ramifications of individual vessels ; or contorted congeries of a 
plexus of the latter, all exhibiting the variations in color of nsevi 
vasculosi, but usually of pinkish or violaceous hue. They are 
unaccompanied by subjective seusatious, are evidently non-inflamma- 
tory in character, and are seen as single or multiple lesions chiefly 
upon the face, but also upon the neck, the backs of the hands, the 
thighs, and other parts of the body. They are not rarely observed in 
connection with other diseases. Thus they occur in the vicinity of 
the lesions of lupus erythematosus, morphoea, acne rosacea, cicatrices, 
and about the contour, or over the surface of many malignant tumors. 
They may therefore have either an idiopathic or symptomatic character. 

The term Rosacea, as distinguished from acne rosacea, is employed 
to designate that condition in which the skin, of the face particularly, 
exhibits a circumscribed or diffuse redness, due to dilatation of the 
capillaries, unassociated with acue or other sebaceous gland disorder. 

The conditions here described as nsevus vasculosus and telangiect- 
asis are displayed in forms which, apart from the question of con- 
genital origin, offer the widest difference and the most bizarre 
combinations. The so-called nsevus flammeus, nsevus aranseus (spider 

30 



466 DISEASES OF THE SKIN. 

cancer), noevus vinosus, " mulberry," "strawberry," and "mother's 
marks" are all examples of these combinations. 

The lesions are often congenital. There is not sufficient proof that 
they are clue to ante-natal maternal impressions. The influence of 
the nervous system in deciding the area of limitation of the congenital 
forms is exceedingly distinct, as, for example, the limitation of a port 
Mine mark to the skin area supplied by one supraorbital nerve. 

Pathology. — Billroth states that the new formation has its origin 
in the vascular network surrounding in basket-like forms the fat 
lobules, follicles, and glands of the skin. Embryonal, vascular 
growths spring from these and as they multiply and develop are 
enforced by proliferation of fibrous, connective, and muscular tissue. 
The color depends largely upon the preponderance of arterial or of 
venous capillaries in the new formation. 

Diagnosis. — The ordinary lesions of angioma are readily recognized 
by their color, size, shape, and obvious vascular constituents. 
Anderson calls attention to the importance of recognizing encephalo- 
cele due to the failure of ossification of the ethmoid and frontal bones 
at the root of the nose. Operations upon such tumors, when sup- 
posed to be angiomatous in character have resulted fatally. Lobula- 
tion, great distention (when a child is crying), a superficial rather 
than deep and complete vascularization of the smooth and glossy 
skin of the tumor, and a double pulsation in it, all point to frontal 
encephalocele. 

Treatment. — The treatment of all forms of angioma, is described in 
detail in the chapter on angioma cavernosum. The best method is 
decidedly that by electrolysis when it is practicable. Then may be 
named excision ; amputation ; injection of pure carbolic acid, tannic 
acid, or the perchloride of iron ; ligature of vessels ; ligation of 
tumors producing strangulation ; the actual cautery ; the galvanic 
ecraseur ; the use of the seton ; and the application of such caustics 
as the ethylate of sodium. Squire's method of multiple puncture 
and scarification has at times failed in the author's hands to accom- 
plish the desired end. 

Angioma Pigmentosum et Atrophicnm. 

This disorder has been also termed Xeroderma Pigmentosum ; Der- 
matosis Kaposi ; Melanosis Lenticularis Progressiva ; and Liodermia 
cum Melanosi et Telangiectasia. 

But a few cases, less than forty all told, have been recorded ; and 
these by Kaposi, Glax, Crocker, Vidal, Pick, Neisser, and Geber, 
abroad ; and, in this country by Taylor, of New York, in an inte- 
resting series of seven cases ; by Duhring, of Philadelphia ; and by 
White, of Boston. The disease results ultimately in a diffuse idio- 
pathic cutaneous atrophy, but this condition is preceded by a general 
hyperemia with vascular dilatation ; the production of numerous, 
punctiform, bright red, pin's-head to pea-sized, flat, or raised telangi- 
ectases ; and disseminated, brownish, and yellowish-brown macula?, 



ANGIOMA. 467 

varying in extent ; between which form superficial, whitish, and 
glossy, atrophic depressions, like the cicatrices of variola. The 
melanosis is at times so uniform and diffuse as to suggest the dark 
tints of the Spanish skin, as in Prof. White's case, with a dense 
spattering of a still darker hue and a blackish scrotum. The 
atrophic or leucodermic condition of the skin may coexist with the 
melanoderma, and present large well-defined areas totally devoid of 
pigment where the skin may have a pinkish tint. The ears may 
thus come to resemble tanned sheep-skin. Prof. White in the case 
under his observation could trace no transformation from a pigment 
macule into a telangiectasia lesion. The skin soon becomes furrowed, 
contracted, and as dry as parchment ; and thus is readily developed 
an eczema or a superficial degeneration, including ulceration. A 
species of furfuraceous desquamation also occurs in patches. The 
faces of most patients exhibit a peculiar checkered appearance, from 
the uniform dissemination over the skin of the pigmented maculae. 
Ectropion, with ulcerative keratitis, epitheliomatous, sarco-carcinoma- 
tous and angio-myxomatous growths complicated several of the cases 
reported ; and in two, certainly, were the immediate causes of a fatal 
issue. Often, however, the general health seems, for long periods of 
time, to remain unimpaired, the subjective sensations being slight. 
Observers of these cases differ somewhat as to the order in which the 
several lesions of the disease appear ; and Duhring thinks it possible 
that no definite order is observed in the evolution of the symptoms. 
Both sexes in early life seem equally predisposed to this disease 
though the large number of members of single families affected with 
its symptoms indicates the importance of predisposition and heredity 
in point of etiology. It is usually first manifested before the third 
year of life. 

It is known that the disease may endure for thirty years. Its 
etiology, pathology, and appropriate treatment are not as yet de- 
termined. 

Angioma Cavernosum. 

This is also termed Tumor Cavernosus. It is distinguished from 
the other angiomatous lesions described above by the peculiarities of 
its formation. It consists of a dense framework of new-formed 
connective tissue, inclosing loculi or chambers of varying capacity, 
containing blood, and communicating not only with each other, but 
with the larger vessels in the vicinity. Whether they originate in 
the fibrous felt-work of the derma, which later establishes a vascular 
connection, or in the vessels themselves, or are constituted by a 
mechanical dilatation of the latter, in consequence of new-formed 
connective tissue in the adventitia, has not been determined. Ac- 
cording to Virchow, they arise generally from coalescence and dila- 
tation of vessels. Other causes are explained by the earlier forma- 
tion of a contracted cicatricial tissue by which vascular distortion 
occurs. (Kindfleisch.) 

They are said to be rarely congenital, developing soon after birth, 



468 DISEASES OF THE SKIN. 

aud to be both superficial, deep, circumscribed, and diffuse. Some- 
times they originate from a ntevus or superficial telangiectasis. 
Often when fully formed, they are distinctly encapsulated. The 
diagnosis is between cysts, fibromata, lipomata, and sarcomata. 
Their rarity in dermatological practice may be explained by the sur- 
gical features of many cases. In five years, no instance of angioma 
caveruosum was reported in the statistical tables of the American 
Dermatological Association. 

Etiology and Pathology. — The causes of the several forms of 
angioma, named above, arc obscure. The symptomatic telangiectases 
are undoubtedly to be explained by obstruction to the circulation 
occasioned by the tumor or other lesions to which they are accessory. 
The foundation for the vulgar belief that maternal impressions are 
responsible for the so-called " mother's marks" is very slight. The 
reputed resemblance of the latter to various flowers and fruits gener- 
ally requires for its recognition a stretch of the imagination. 

Anatomically, these lesions are recognized as due to dilatation and 
formation of venous aud arterial capillaries in the superior portions 
of the derma, the vessels of the newly formed plexus freely com- 
municating with each other. Generally there is a simultaneous new 
formation of connective tissue constituting the framework of the 
growth, which varies considerably in the different forms of the dis- 
ease. Lobules constituted of coils of capillary vessels are often 
separated by it into distinct masses. According to Heitzmann, the 
large spaces of angioma cavernosum imitate the structure of the 
corpora cavernosa of the penis, and are filled with venous blood, 
being separated from each other by a scanty fibrous connective tissue. 

Treatment. — The treatment of this group of new growths is, in 
general, limited to a series of local surgical procedures. These all 
have in view either the destruction of the new growth, or the arti- 
ficial production of an inflammation, in order to obliterate the lumen 
of the capillaries of which it is composed, to an extent sufficient to 
interfere with the transmission of the blood-current. 

First among these is electrolysis. One or a set of several fine 
cambric needles, with their points at the same plane, are connected 
with the negative pole of an ordinary zinc and carbon battery of ten 
to twelve cells. The points of the needles are quickly passed into 
the tissues, and there held for a period of between ten to thirty 
seconds, according to the effect produced after completion of the 
circuit. The new growth is thus blanched in the vicinity of the 
needles, this effect disappearing in the course of a few moments. In 
about three weeks, the curative result of the operation becomes ap- 
parent. According to Fox, 1 of New York, the objections are that 
the operation is sometimes painful and tedious, and may occasionally 
result in the production of suppuration, superficial sloughs, minute, 
keloid-like elevations, vascular nodules, depressed scars, or superficial 
ulcers. The author has operated in scores of cases without the pro- 

i New York Med. Rec, FeL>. 18, 1882, p. 188. 



ANGIOMA. 469 

ductiou of any results worse than the original disfigurement, often 
with complete success. 

The method of Sherwell 1 is by multiple puncture with a set of 
fine needles in a holder similar to that described above. These are 
dipped in a twenty-five to fifty per cent, solution of chromic acid, 
and then made to penetrate the part to be attacked. The bleeding 
is readily arrested by pressure, and then the patch is to be covered 
with several superimposed layers of flexible collodion. This pro- 
cedure is of value in circumscribed patches of superficial character 
and relatively limited area. By it, the author has succeeded in re- 
moving port-wine marks in three patients, with the result of pro- 
ducing a somewhat irregular cicatriform tissue much less disfiguring 
than the original blemish. One of these patients was repeatedly 
exhibited at the clinic during the progress of the case. 

Squire's operation is done upon previously frozen patches by the 
aid of an instrument which destroys the vessels by making numerous 
crossed and closely spaced linear incisions, parallel to each other and 
in a plane obliquely directed to that of the integument. Here also 
bleeding is arrested by pressure, exerted before the circulation is re- 
stored. The operation has been, in hands other than his own, at- 
tended at times with unsatisfactory results. 

Sodium ethylate, a compound in which the radical ethyl in ethylic 
alcohol is united with sodium, is a caustic recommended by Richard- 
son 2 in the treatment of nsevus. It is applied by means of a glass 
rod. A first application usually results in the formation of a dense 
crust under which the nsevus contracts, and repeated applications are 
made at intervals of a few days till the desired result is obtained. 
The sodium ethylate should be pure, and the crusts should not be 
disturbed till they fall spontaneously. In one case observed by the 
author, there was a persistent redness of the resulting scar which 
was decidedly open to objection. 

Other methods employed are the ligature when practicable ; punc- 
ture with hot needles; the topical application of caustics other than 
those named above, such as hydrate of potassium, nitric and carbolic 
acids, and corrosive sublimate; and total excision, the latter being 
practicable in relatively small growths. The galvano-cautery and 
the thermo-cautery are both valuable in the destruction of the 
capillaries, and have repeatedly proved successful in my hands. For 
telangiectases and naevi no larger than a pea, the Paquelin knife is 
an efficient resort. The old method of multiple vaccination about 
and upon the involved area is frequently followed by the best of 
results, and whether in consequence of the retraction of tissue under 
the influence of the inflammation excited, or of the destructive re- 
sults of the suppuration induced, or of an indefinite caustic effect, is 
not, as Kaposi suggests, quite clear. 

These results may be partly imitated by the induction of superfi- 
cial pustulation and suppuration through the medium of tartar 
emetic and crotou oil, methods which certainly should be considered 

i Archives of Derm., Oct. 1879. " Lancet, November 9, 1878 



470 DISEASES OF THE SKIN. 

clumsy in the light of recent successes, obtained by more manageable 
expedients. 

Injections with carbolic acid and the perchloride of iron, though in 
very few cases followed by fatal results, are often brilliantly suc- 
cessful. 

Coombs 1 has lately modified somewhat the method most in vogue, 
by passing fine silver wires through nsevous growths, and connecting 
the extremities with a Bunsen's battery. When the wires are heated, 
the circuit is broken, and the ends of the wires disconnected from the 
battery and united to each other, being then left in situ and covered 
with lint and plaster. The current can then be passed repeatedly 
without reinsertion of the needles, and the latter need be withdrawn 
only when the cure is complete. 

The treatment of angioma cavernosum mauifestly requires surgical 
interference. 

The prognosis in any case of augioma will evidently rest upon the 
method of treatment adopted for its removal. In the larger number 
of cases, the lesions having attained a maximum development, persist 
without further pathological change, constituting a deformity rather 
than a disease. Physiological alterations in the color of such lesions 
occur under the influence of changes in the circulation. 

Lymphangioma. 

Lymphangioma of the skin is an ectasia or new growth of lymphatic vessels 
of the corium, spontaneous or traumatic in origin, producing usually cysts 
containing lymph. 

New growths of lymphatic vessels in the skin have been noted as 
constituting a cutaneous disease proper, by Hebra and Kaposi, Pos- 
pelow, 2 Van Harlingen, 3 and a few other writers. By the authors 
first named, the disease is termed Lymphangioma Tuberosum Mul- 
tiplex. The lesions in these several cases were multiple, pea- to 
bean-sized, smooth, roundish, reddish, lilac-tinted or bluish, firm or 
compressible tubercles, implanted in the skin, and occurring first in 
early life, about the neck and trunk. Some of these were quite 
reducible under pressure, aud transparent. In Van Harlingen's case, 
the lesions were destitute of fluid contents, and also interspersed 
between telangiectases. Anatomically, roundish or oval spaces 
appeared in sections, recognizable as distended lymphatic vessels by 
the characteristic endothelium with which they were liued. Kaposi 
distinguishes these tubercles from all subcutaneous cavernous tumors 
constituted of new-formed dilated lymphatic vessels reaching toward 
the skin, by the limitation in the former of the neoplastic growth to 
the superior parts of the corium. 

In comparing these with the large number of cases of congenital 

i London Lancet, 1881. 

2 Viertel.j. f. Derm. u. Syph., Hft. 4, 1879. 

3 Paper read before the Amer. Dermat. Association, September, 1881. Phila. Med. Times, September 
24, 1881. 



EHINOSCLEROMA. 471 

and acquired dilatation of the lymph channels, collated in the valu- 
able monographs on these subjects by Dr. S. C. Busey/ of Wash- 
ington, D. C, a further special difference between the two becomes 
apparent. In the latter, when the lymph-filled vesicle, papule, or 
tubercle, which appears upon the integument is ruptured, there at 
once supervenes an exhausting drain from the body, of pure, coagu- 
lable lymph, a feature which is not described by the dermatological 
authors named, as of occurrence in their cases. 

Most of the diffuse forms of lymphangioma, those of the class last 
described, constitute firm or lax tumors of such size as to be termed 
Elephantiasis Lymph an giectatica or Pachydermia Lymphangiectatica. 
These contain often large lymph-filled sacs or lacunae, enveloped in 
hypertrophied muscular and connective tissue, and an cedematous 
integument. Some of the elephantiasic deformities of this character 
are fully as enormous as the extreme distortions of elephantiasis 
proper. 

Lymphadenectasia is a name given by Virchow to tumors usually 
in the axillary or inguinal regions where the lymphatic vessels in the 
lymphatic glands dilate or multiply so as to form large tumors. The 
lymph-scrotum due to the presence of the filaria sanguinis hominis is 
elsewhere described. 

Lymphangiomata may be congenital or appear soon after birth. 
Their cause is unknown. Anatomically the lesions are found to 
consist of greatly developed lymphatic vessels, lined with endothelium 
and enveloped in small-celled connective-tissue stroma. The treat- 
ment, of the larger lesions only, is surgical. 



Rhinoscleroma. 

Gr. pig, or plv, the nose ; and onlripSg, hard. 
Ehinoscleroma is an infectious granuloma affecting the skin and mucous mem- 
branes of the nose and contiguous parts, characterized by the formation of 
exceedingly dense, elastic, and painful, flattened or elevated plaques, 
nodules, or tubercles, which may be isolated or confluent. 

Symptoms. — A knowledge of this rare disease, first described by 
Hebra and Kaposi in 1870, 2 has been obtained solely from a study 
of some forty cases chiefly observed by these authors. The following 
is a concise statement of their description of the malady : 

The disease commonly begins in the septum or a single ala of the 
nose without inflammatory symptoms. The involved parts slowly 
enlarge, and become finally as dense as ivory. The individual lesions 

1 Congenital Occlusion and Dilatation of the Lymph Channels (Amer. Journal of Obstetrics, January, 
1877, et seq.) ; Narrowing, Occlusion, and Dilatation of Lymph Channels, Acquired Forms (New Orleans 
Medical and Surgical Journal, No. 3, 1876, to No. 8, 1878, inclusive). See, e. g., history of Berkley 
Hill's patient, p. 101; of Zambuco's, p. 120 ; of Carter's, p. 103 ; of Oholmley's, p. 136 ; of Jackson's, 
p. 173, and many others. 

2 Wien. med. Woch., No 1, 1870. 



472 DISEASES OF THE SKIN. 

are Hat patches, or elevated and circumscribed nodules, papules, and 
tubercles, painful upon pressure, movable to a certain extent over 
underlying tissues, and covered either by a normal integument, or a 
light or dark red, shining, vascular epidermis. Neither hairs nor 
glands are discernible over the lesions. As the disease progresses, 
the aire become enlarged, flattened, and so indurated that they cannot 
be pressed together, while respiration may be impeded by stenosis of 
the nares. The process may extend to the neighboring parts, 
involving thus the upper lip, gums, velum, epiglottis, and larynx, 
the teeth meanwhile falling from their sockets and the soft palate 
becoming in some cases perforated. Involution of the process has 
not been observed, as the lesions do not degenerate by ulceration. 
Mas Zeissl, 1 however, reports a single case in which there had been 
ulcerative destruction of the entire left nostril, as well as the tip and 
right ala of the nose. Occasionally superficial excoriations have 
occurred, but very rarely a diminution in the consistency of the mass. 
The disease is exceedingly chronic, requiring years for its develop- 
ment ; and though the affected parts are painful on pressure, they are 
otherwise not the seat of subjective sensation. 

Etiology and Pathology. — The disease is observed between the 
fifteenth and fortieth years in persons of all social conditions and 
individuals of both sexes, free from syphilitic, strumous, tubercular, 
and other cachexia. 

Kaposi originally observed, as anatomical lesions of the disease, a 
dense infiltration of the corium, and its papillary layer, with small* 
closely packed elements, which he recognized as a true new-formation. 
He considered this as analogous to the small-celled sarcoma, iuasmuch 
as Mikulicz, Geber, and Billroth have seen some of the elements of 
the neoplasm transformed into osseous formations sufficiently common 
in sarcomatous tumors. 

More lately, however, A. v. Frisch, after examining tissue 
removed from lesions of rhinoscleroma in twelve patients, found in 
the cells and between them in the interpapillary fissures of the 
connective tissue, bacteria distinctly rod-shaped, one and one-half 
times longer than they were broad. These germs were successfully 
cultivated, but experimental inoculations with culture fluids thus 
obtained were negative in results. Neisser in a single case found 
no bacteria ; nor did Davis have better success in studying sections 
removed from his patient, the first reported as occurring in Egypt. 2 

Dreschfeld, 3 however, found in sections of tissue obtained from 
Payne's patient numerous bacilli less slender and smaller than those 
occurring in tuberculosis with slightly thickened extremities. These 
were unlike those exhibited by Paltaup, at the Berlin Congress, who 
regarded them as similar to if not identical with Friedliiuder's pneu- 
mococcus. Barduzzi, Pellizari, and others have added to the evidence 
in favor of the parasitic nature of the disease. 

i Wien. med. Woch., 1880, p. 021. 

2 Brit. Med. Journ , May 29, 188tS. 3 Brit. Med Journ., October 24, 1885. 



LUPUS ERYTHEMATOSUS. 473 

Diagnosis. — The disease can hardly be mistaken for another in 
consequence of its situation, the disfigurement it occasions, the ivory- 
like elasticity and induration of the affected parts, and the rarity of 
ulcerative degeneration. As distinguished from syphilis, it is known 
to be entirely unaffected by specific medication. From the variety 
of acne rosacea of the nose, known as rhinophyma, it is readily 
differentiated by the softness and compressibility of the latter, and 
its evident vascular and glandular composition. 

The ulcerations of epithelioma have a more circular outline, a 
more elevated edge, and occur in persons of a more advanced age. 
Keloid, if found in the situation of rhinoscleroma, does not ulcerate. 

Treatment. — The method of relief thus far employed is a total or 
partial extirpation of the neoplasm. Kaposi speaks of dilatation of 
the nares by means of laminaria and compressed sponge, where there 
is actual or threatened nasal occlusion. Both excision by the knife and 
destruction by caustics have, however, been found to secure merely 
temporary benefit, as the growth is reproduced with some rapidity. 

Prognosis. — The future of the patient is grave. The disease not 
only persists and recurs after operative interference, but may endanger 
life by obstruction of the nostrils. Zeissl's case 1 proved fatal in ten 
years after the disease first appeared. 

Lupus Erythematosus. 

Lat. lupus, a wolf. 

Lupus Erythematosus is a cutaneous new growth, displayed to the view in 
well-defined, slightly raised, discoid patches, often with a depressed or 
atrophied centre, colored in various shades of hyperemia, covered with 
adherent, yellowish-gray scales, and terminating, after a favorable involu- 
tion, by the production of a persistent scar. 

This disease was first described by Biett under the title Erythhne 
Centrifuge. Hebra, in 1845, described it among the seborrhoeas as 
Seborrhoea Congestiva. Its present title was given by Cazenave in 
1850. It is also termed Lupus Erythematodes, Lupus Sebaceus, 
Lupus Superficialis, and " Scrofulous Ringworm." 

Symptoms. — The disease is first exhibited in one or several rape- 
seed to bean-sized, reddish maculae, slightly elevated from the surface, 
and covered with a peculiar glistening epidermis, or with an adherent 
scale. 

When but a single patch is formed, the primary lesion described 
above enlarges its periphery, in the course of months or years, by a 
slowly continuous development. Its reddish outer rim is then 
distinctly elevated, while its centre is depressed, showing either 
adherent, yellowish-gray scales, or a glistening appearance of the 
unbroken epidermis. It may thus attain the size of a small coin or 
a large saucer, and occur in this form symmetrically or asymmetri- 
cally about the cheeks, nose, eyelids, forehead, ears, scalp, mouth, 

i Wien. med. Woch,, 1880, p. 621. 



474 



DISEASES OF THE SKIN. 



hands, and feet. The disks or patches arc very well defined in out- 
line, and of a eolor varying with the complexion of the patient, from 
a rosy-pinkish to a deep purplish hue. The shape is usually circular, 

oval, or in figures representing combinations of these outlines. The 
scales, too, vary in color, being at times of a clear white or whitish- 
yellow, and again, often from concurrence of comedones, of a leaden 
or brownish tint. The latter are usually scanty and adherent, but are 
also, rarely, abundant. They can be occasionally seen firmly fastened 
to the orifice of the excretory duct of a sebaceous gland. When such 
a patch spreads symmetrically over the brow and cheeks, its figure 
has been likened by Hebra to the open wings of a butterfly. The 
disease is never accompanied by the occurrence of other cutaneous 

Pig. 58. 




Lupus erythematosus of the face (fr. 



f the author's patients). 



lesions; nor is it ever displayed in symptoms of moisture and dis- 
charge. 

When the macuhe originate as multiple lesions, the evohition of 
the disease may be accomplished by increase in the number of the 
former, rather than, as just described, by the peripheral extension of 
a single patch. The disease is then apt to be manifested, not only 
in the regions named above, but over the trunk and extremities, 
where it is likely to assume atypical forms, and be complicated by 
accesses of a febrile or neuralgic character, and by various cutaneous 
accidents, such as erysipelas, dermatitis, etc. 



LUPUS ERYTHEMATOSUS. 475 

The disease is remarkably chronic in its course, lasting in cases for 
a quarter of a century, and throughout not interfering with the 
general health. So-called " galloping" cases are described by French 
writers, where visceral complications were the causes of a fatal result. 
The disease varies in the subjective sensations it produces; being at 
times accompanied by excessive itching, and often by no discomfort. 
It is much more common in women than in men, and is a disease of 
adult years. Kaposi reports a single case in one child three years 
of age. 

The scars left by the affection are indelible and characteristic. 
They are generally uniform and superficial ; can be readily pinched 
up between the thumb and finger ; are of a dull, whitish tint, and 
rendered punctate in a peculiar manner, suggesting the action of the 
engraver's tool in what is known as the " stippling " process. They 
are never pigmented, puckered, radiate, stellate, corded, or deeply 
attached. 

According to some authors there are two varieties of erythematous 
lupus, the first, the so-called discoid form, described above ; second, 
a disseminate form. In the latter, graver in type, the disease begins 
with numerous efflorescences of the character already described which 
multiply without marked enlargement of any single disk until very 
extensive surfaces are involved including the trunk, extremities, and, 
in generalized forms, almost the entire body. There is often coinci- 
dent fever or erysipelatous complication, and the result may be a 
typhoid condition with fatal result. These cases are not known in 
America and Great Britain. Boeck has described two cases of this 
sort observed in Norway. 

Lupus erythematosus of the hands, observed rarely in France and 
Germany, more often decidedly in England and America, occurs not 
only in the generalized forms referred to above when large areas of 
the body are involved, the hands included ; but also when the lesions 
are exclusively manual in situation. These cases have been described 
by Hutchinson, Sir Erasmus Wilson, and others, including the 
author. 1 The lesions are not to be mistaken for chilblains on the 
hands. Very rarely they are seated upon the glans penis. 

Etiology. — The causes of lupus erythematosus are unknown. 
Much has been said and written to prove that the disease is of scro- 
fulous origin, but inasmuch as an immense number of scrofulous 
patients in all parts of the world never exhibit traces of the disease, 
it is needless to say that the proof has not been obtained. In by far 
the larger number of patients actually displaying characteristic disks 
of erythematous lupus, the usual concomitants of scrofuloderma 
(which see) are actually wanting. In many patients, the most 
careful investigation fails to discover any other evidence of ill health. 
Yet inasmuch as many young women, after the puberal epoch, suffer 
from the chlorosis, ansemia, and menstrual irregularities common to 
their sex and age, these conditions may concur. As for tuberculosis, 

1 See his resume of these cases in the Journ. of Cutan. and Vener. Dis., Nov. 1884. 



476 DISEASES OF THE SKIN. 

adenopathy, and malnutrition, cases of erythematous lupus occur in 
subjects affected with such symptoms to an extent which may pos- 
sibly be the result of coincidence. Considering the remarkable 
rarity of the disease, and the no less significant frequency of sebor- 
rhea, the wonder is not that they should occasionally concur, or be 
transformed, the latter into the former, but that such phenomena are 
not more conspicuously and frequently noted. 

The disease is more common in women than in men, usually ap- 
pearing first in the third decade of life, in this particular presenting 
a contrast with lupus vulgaris. 

It is reported to have followed acne, seborrhcea, variola, erysipelas, 
vesication with cantharides, and the traumatism of leech-bites. The 
author has seen it in one case appear when the curette had been 
employed in a patient with a characteristic patch elsewhere on the 
face. 

Pathology. — The disease -process originates either in the peri- 
glandular tissues of the sebaceous or sudoriparous follicles and their 
ducts, or in some part of the panniculus adiposus; in other words, 
from any point in the superficial or deep strata of the cutaneous or 
subcutaneous structure. Under the microscope, the elements of both 
the epithelia lining the glands and of the connective tissue without 
are seen to be multiplied and largely commingled with the ordinary 
products of an inflammatory process. 

Thin 1 fouud enormous distention of the capillaries in the papillae, 
their loops of venules being choked with red blood-disks, and in 
this state almost completely occupying the digitation. The same 
was observed in the perifollicular plexuses, while yet the rete and 
glands were quite unaffected. Such alterations would, without ques- 
tion, ultimately follow as the result of the vascular trouble ; but the 
observations are of interest as lending color to the supposition that 
the primary changes in lupus erythematosus are chiefly vascular. 
Similar vascular dilatations, papillary and perifollicular, have been 
noted by Kaposi and others as concurrent with structual alterations 
in other portions and appendages of the skin. 

In consequence of the new growth thus formed, there are moderate 
elevation of the initial macule of the eruption and a thickened rim 
to its centrifugally developing patches. Central resorption or 
atrophy of the same material in the epidermis and corium of such a 
patch explains the wasting and depression so frequently observed in 
each. By the destruction of the glandular and connective tissue 
elements in the course of a retrograde metamorphosis, a loss is pro- 
duced which is made good by the peculiarly punctate form of the 
cicatrix which results. 

Veiel classes the disease among the superficial inflammations of 
the skin. 

Diagnosis. — The facies of the patient, with lupus erythematosus 
of that region, is usually so characteristic that the disease is there 

i Mod. Clin. Trans., 1S75. 



LUPUS ERYTHEMATOSUS. 477 

recognized with ease. When the hand and other portions of the 
body are involved, the diagnosis is somewhat less readily established. 
In the former situation, the disease has a predilection for the dorsum, 
and invades the palm usually only by extension to it from behind. 

From lupus vulgaris it may be recognized, by its occurrence 
originally at a later period of life ; by its greater tendency to sym- 
metry; and by the absence of nodules, ulceration, and extension to 
the deeper portions of the skin or underlying structures. 

In eczema, there is usually some history of moisture; in ery- 
thematous lupus, never. In eczema, also, the itching is a more per- 
sistent and distressing symptom; but the acuteness of even chronic 
eczema, as compared with lupus erythematosus, will suffice to dis- 
tinguish the two diseases. Psoriasis is rarely, if ever, limited to a 
single patch on the face; it is also characterized by more lustrous 
and more readily exfoliating scales. Its patches are, furthermore, 
uniformly well covered with scales, and of equal flatness in all 
parts, while those of lupus erythematosus are irregularly squamous, 
the scales being often clustered at the orifices of the ducts of the 
sebaceous glands, while the rim of the patch, is elevated and the 
centre depressed. 

In acne rosacea, there are marked telangiectases and papulo-pus- 
tules or nodules which are not found in erythematous lupus. In 
tinea circinata, there may be a clearing, but never a cicatriform 
centre of the circular disk. The circular serpiginous syphiloder- 
mata of the face occur usually with other manifestations of lues, are 
characterized by a much darker hue of the dense infiltration, and 
exhibit distinct signs of ulceration in most cases. Cicatrization 
or atrophy of the skin without preceding ulceration, is the sign and 
seal of typical erythematous lupus. 

Treatment — The internal treatment of this affection is not highly 
satisfactory. Often none is indicated or required. Anderson 1 highly 
recommends the trituration of twenty-four grains (1.6) of iodine 
with a little water, adding to this one ounce (32.) of starch, till a 
uniform deep blue, almost black color is obtained, after which the 
iodide is dried by gentle heat. A large teaspoonful is given in a 
little gruel three times daily. The administration of the iodide of 
potassium, arsenic, and iodoform has also been followed by note- 
worthy results. In general, however, cod-liver oil and the chary - 
beates will be found most serviceable, in connection with such 
hygienic regimen and diet as are in each case specially indicated. 

The local treatment of the patches of disease is of importance. 
Inasmuch as the affection is one whose involution is occasionally 
accomplished under the influence of mild topical applications, and is 
succeeded very rarely by grave sequela?, it is evident, that the simpler 
measures should be first adopted. Of these, green soap, applied as 
a plaster, or in the form of the spiritus saponis viridis, is most ser- 
viceable. It not only cleanses the patch of its scales, but stimulates 

i Brit. Med. Journ., May, 1880. 



478 DISEASES OF THE SKIX. 

the surface, often to the extent of inducing a reparative process. 
The patch may he briskly rubbed, either with the soap or the spirit, 
in combination with hot water, after which an ointment may be ap- 
plied, preferably sulphur, in the strength of two drachms (8.) to the 
ounce (32.) of petroleum ointment. When a decided effect is pro- 
duced, the spirit may be discontinued, and the hot water and unguent 
for a time employed alone. A decided and beneficial effect can be 
noticed at times after the topical application of very hot water alone, 
sopped on the parr for twenty minutes at a time with a small sponge 
mounted on a handle. 

The following is a gentle stimulant: 

M. ZiiK-i sulphat. J aa 3ss • 2 
Potassii Bulphuret. J 

Spts. vin. rectif. ffcuj; 12 

Aq. rosar. f^hjss; 312 

To be diluted as required for external use. [Dubrin 

The following is a formula for a stronger lotion : 

M. Cbrysarobin. Sijss; 10 

Acid, salicylici } -- _ „ 



Calami nis pulv 
Athens f3j ; 4 

Collodii flex. f^v; 20 

Sig. To be applied with a brush. 



M. 



For this may be substituted pyrogallol, in the strength of half a 
drachm (2.) to the ounce (32.) of salve. 

Other substances for local applications are: the tars, iodized 
phenol, iodized glycerine, the iodide of sulphur, iodide of potassium, 
iodine in fine powder and tincture, naphthol, ichthyol, and chloracetic 
acid. Ohrvsarobin and pyrogallol have a decidedly favorable effect, 
subject, however, to the inconvenience of staining the skin, a promi- 
nent objection in the majority of eases where the disease is displayed 
upon the face. Upon the hands the author has employed chrysarobin 
with the effect of producing a typical cicatrix in the course of a 
month when the disease had lasted for two years. 

Erasion by the dermal curette, in accordance with the method pro- 
posed by Dubini, of Milan, and popularized by Volkmann, of Halle, 
has been successfully practised by many operators; as also the treat- 
ment by multiple punctures. These have not met with the favor 
in lupus erythematosus which has been accorded them in lupus vul- 
garis; while multiple incisions by the lancet, or the instrument 
devised bv Balmanno Squire 1 have been rewarded with greater success. 
The instrument of the latter makes sixteen simultaneous superficial 
incisions in the patch previously frozen by the ether spray. Vidal 2 
lays stress upon attacking in this way the peripheral zone of the 
lesions. 

In exceedingly obstinate cases, those especially where the elevated 
rim of the erythematous disk refuses to yield to the simple measures 

i British Medical Journal, May, 1880. * Le Praticien, Nov. 14, 1881. 



LUPUS VULGARIS. 479 

described, a solution of caustic potassium in distilled water, one part 
to two or four, may be gently applied with a camel's-hair brush, and 
the alkali immediately neutralized by the addition of dilute muriatic 
acid, as soon as the desired effect is produced. That effect, it must 
be remembered, is superficial cauterization only. AYhen the sero- 
sanguineous exudation and reactive effects disappear, the rim is seen 
to be flattened and to have lost in part its violaceous blush. After 
such severe application, which should never be trusted to the hand 
of one unskilled in its use, an anodyne cerate should be spread over 
the part, containing morphia or opium. 

Vesication with cantharides, recommended by Anderson, has been 
endorsed as valuable by several authors. The same may be said of 
the mercurial plaster, of which Kaposi speaks highly j while he and 
others agree that carbolic, salicylic, nitric, chromic, and sulphuric 
acids, the chloride of zinc, the other mercurial preparations, and 
arsenical pastes, are of less value. 

I have used electrolysis with benefit in a few cases, passing the 
needle connected with the negative pole of the battery deeply into 
the involved tissue. Among other useful applications may be named 
pure creasote, white precipitate salve, Unna's gutta-percha plaster- 
mull of pyrogallol, iodoform, and the zinc oxide pastes (see p. 82). 

Prognosis. — A favorable opinion with respect to the future of the 
disease can never be safely given ; though, as regards the general 
health and comfort of the patient, there can rarely be question. At 
the same time the affection is capricious in its course, and may on 
occasions, after long periods of obstinate persistence, very rapidly 
improve under the simplest treatment. It is liable to relapse, though 
not to frequent recurrence. 

Lupus Vulgaris. 

Lat. lupus, a wolf. 

Lupus Vulgaris is a neoplastic growth in the skin or contiguous mucous mem- 
brane, manifested in the production of slowly developing, reddish-brown 
nodules, whose involution, in certain cases, is succeeded by ulceration and 
the production of a cicatrix. 

This disorder has also been termed Lupus Exedens, Lupus Vorax, 
and Scrofulide Tuberculeuse. Late discussion of the question of its 
extent, nature, and relations to other diseases, has been prolific in 
the production of an enormous mass of literature devoted to the 
subject, of which there is not space in a treatise of this scope for more 
than the briefest conclusions. 

Symptoms. — The disease is characterized at its outset and throughout 
its career, by the development of numerous, softish, isolated, sub- 
epidermic nodules, varying in size from a millet-seed to a hemp-seed, 
encompassed by the derma, and betrayed to view in the epidermis 
by punctiform maculations of a reddish-brown color, which fade under 
pressure with the finger. 

It is the subsequent evolution of these elements in each lupous 



480 DISEASES OF THE SKIN. 

eruption, often, indeed, somewhat difficult to appreciate, which fur- 
nishes each variety of the disease. Thus they may be disseminated 
irregularly as in segments of circles (Lupus Disseminatus, Lupus 
Serpiginosus) ; or developed in bulk to the size of papules or 
tubercles (Lupus Tuberculosus); or proceed to involution by 
atrophy and desquamation (Lupus Exfoliativus) ; or by ulceration 
(Lupus Vorax, Lupus Exedens); or be the seat of proliferating 
vegetation (Lupus Vegetans, Lupus Hypertrophicus); or of 
corneous and papillomatous growths (Lupus Verrucosus). 

Fig. 59. 




Lupus vulgaris of the face (from a photograph of one of the author's patients). 



Under the title of Lupus Sclerosus (Lupus Sclereux), Vidal, in 
1883, described a form having a cicatricial centre, a circinate outline, 
and a firm elevated border, located often upon the hands. 

A number of other names are employed to designate unessential 
features of the disease, according as its lesions appear in lines, with 
well-defined margins, or display elephantiasic, acute, chronic, and 
other phenomena. 

The disease is quite rare in this country, and when seen is usually 
in papular or tubercular phases. The lesions are then commonly 
agglomerated in patches; and vary in consistency, size, and depth of 
involvement of the derma and subcutaneous tissues, though often 
distinctly circumscribed in outline. If involution occur, the papulo- 
tubercles flatten by atrophy, and the shining, tense, and imperfectly 
formed epidermis with which they were covered, exfoliates, leaving a 
cicatrix beneath. 

When ulceration of the patch occurs, a suppurative, and often 
painful inflammation precedes; the ulcer, if the secretion it furnishes 



LUPUS VULGARIS. 481 

be permitted to dry upon its surface, very slowly spreading beneath 
the crust. The lupous ulcer has a dirty, purplish-red, indolently 
granulating or hemorrhagic floor ; a generally circular outline ; soft, 
neither elevated nor undermined edges ; and a discharge which is 
sufficiently abundant to drip freely from an exposed surface, or to 
dry in peculiar, broad, flat, rather uniformly homogeneous crusts. 

The nose is the most frequent seat of lupus, and this organ it may 
reduce eventually to a mere atrophied miniature of its former size, 
or utterly destroy by exteusive ulcerative invasion of its integument, 
mucous membranes, and cartilages. It occurs also upon the cheek, 
chin, ears, lips, lids, scalp, neck, genitals, buttocks, and extremities. 
At times, two or more distant regions are affected. The author has 
at preseut under his charge a young Englishman with a palm-sized 
lupous patch upon and beneath the chin, and a large platter-sized 
exulceration on the right buttock and thigh, both of which have 
tormented him from his earliest childhood. 

One of the most conspicuous features of lupus vulgaris is its essen- 
tially chronic course. Compared with other chronic infectious 
diseases it requires far more time for its complete evolution than 
either syphilis or carcinoma ; and in this point is best compared with 
lepra. For a quarter of a century, a lupous patch may be limited to 
a space no larger than the palm of the hand ; and exhibit some 
evidence of activity during the greater part of that period of time. 

A form of lupus vulgaris, not very rarely observed, produces 
extensive changes in the skin (more particularly of the face) without 
ulcerative effects. Here a large portion of the skin of the head 
(cheeks, lips, nose, lids, chin, ears, brow, and neck) becomes altered 
by the lupous new growth. The resulting thickening produces a 
marked and characteristic deformity reducing the openings of the 
mouth and lids to narrow slits, interfering with vision, speech, and 
mastication, and producing a marasmus from these causes alone 
before there is ulceration at a single point. 

The ravages of the disease are at times frightful in severity ; not 
merely in consequence of the destructive ulceration to which it tends, 
but from the deformity left by its awkward attempts at repair. The 
entire head may be thus converted into a hideous travesty of humanity, 
while yet its possessor is left with all his vital organs and functions 
apparently unimpaired. 

Etiology. — Lupus vulgaris is generally first seen between the third 
and sixth years of life; after the thirtieth year practically never, 
unless there have been prior symptoms of the disease. It is not 
congenital in origin, nor limited to either sex, nor to individuals of 
any social grade. It occurs in the anaemic and the asthenic ; in the 
scrofulous, the tuberculous, and those free from such disorders. It 
is much rarer in this country than abroad, occurring here with nearly 
the frequency of lupus erythematosus. It is in no way related to 
either acquired or hereditary syphilis. 

The author is in practical agreement with Neisser, who believes 
the disease to be a " partial manifestation of tuberculosis." Though 

31 



482 



DISEASES OF THE SKIN 



the actual demonstration is yet wanting, the proofs at hand point 
conclusively to the feet that lupus vulgaris should be classed with 
the infectious granulomata. The author has elsewhere called atten- 
tion to the striking fact that the disease is commonly first manifested 
at the early period of life, when the habit is not yet established of 
keeping the soiled hands away from the face. Infection of the skin 
with the bacilli of lupus would thus produce, as is the fact, facial 
lesions in tin- majority of all cases and lesions of other exposed parts 
of the body (bare legs of children) in the order of ease with which 
they might become the .-eat of infection. 1 



Fig. 60. 




d d 

Section of .1 lupous nodule. 6, normal curium ; «, reticulum with lupous elements in groups; 
c, d, giant cells. (After Kaposi.) 

Pathology. — For a knowledge of the microscopic characters of lupus 
vulgaris we are largely indebted to the Germans, whose opportunities 
for the study of the disease are unequalled. Virchow, Auspitz, Bill- 
roth, Lang, Kaposi, Klebs, Stilling, and Thin, of England, have 
amply contributed to the subject : and the result of their investiga- 
tions may be concisely stated as follows : 

1 Relations of Lupus Vulgaris to Tuberculosis, Journ. of Cutan. and Vener. Dis., Nov. 1885. 



LUPUS VULGARIS. 



483 



The more recent nodules when divided exhibit at different depths 
of the corium roundish masses, comparable to a nidus or nest, above 
which spreads an unaltered epidermis. These foci of the disease are 
well denned in outline, and of a reddish-yellowish tint. Around 
them is woven a network of connective-tissue bundles ; with larger 



Fig. 61. 




Section of lupus of face. X 750 and reduced. (Delafield and Prtjdden.) 

and smaller interspaces containing vascular elements, and also cells 
and nuclei, probably masses of protoplasm originating in the rever- 
sion of the connective-tissue elements to the embryonal state, 
lletrogression is marked by a diminished vascularity ; while the 
elements disappear by resorption, or by the destructive process of 
ulceration followed by the cicatrix. Both Kaposi and Lang agree 
that the vascular and fibrous elements of the lupous mass are capable 
of developing new connective-tissue which later undergoes retraction. 
This is curiously in accord with the clinical result of Squire's treat- 
ment by multiple linear scarification, in which the lupous growth, 
after replacing the normal elements of the derma, becomes itself the 
source of the new material of repair. 

When the disease is extending, the lupous growth, spreading along 
the vascular elements of the derma, involves finally the rete and the 



484 DISEASES OF THE SKIN. 

panniculua adiposus. Tlie nest-like agglomerations disappear; there 
is in their stead an irregularly diffuse infiltration, producing subse- 
quently hypertrophic, atrophic, desquamative, suppurative, or ulcera- 
tive sequelae. Finally, the glands of the skin may become involved, 
the hairs falling from their follicles, the sebaceous glands either 
becoming obliterated, or having their acini stuffed with epidermal 
masses which distend them in milium-like bodies grouped about a 
cicatricial pedicle. When, as observed by several authors, there is 
coincidence of lupus vulgaris and epithelioma, the latter is developed 
from epithelial cones, described by Kaposi as penetrating downward 
and in other directions from the coil-glands and the root-sheaths of 
the hairs. 

The discovery of bacilli in lupous tissue, first made by Koch, has 
been since verified by Doutrelepont, Weichselbaum, Meisels, Schiiller, 
Lustig, and others. The striking resemblance first shown by Vir- 
chow between a caseous miliary tubercle and a lupous nodule had, 
even before his discovery, pointed to an identity of origin. 

The result of inoculation of culture fluids has given positive results. 
Lenz, Hiiter, Schiiller, aud others, have produced tuberculosis in 
rabbits, by introducing within the eye granulations taken from 
lupous patients. 

The bacteria of lupus are rod-shaped, and in length from one- 
fourth to one-half the diameter of a red blood-corpuscle. They are 
usually found within the cells, aud commonly but one is visible in a 
single cell. They are, however, also found free in the lupous tissue. 
Some contain roundish or oval spaces. They are more abundant in 
recently formed lupous nodules exhibiting some pathological activity. 

Diagnosis. — Epithelioma, though rarely resembling lupus vul- 
garis, is more often designated by that than by any other false title. 
Great confusion has arisen from the looseness with which several 
surgical authors have furnished illustrations of " lupus exedens," 
which were really pictures of cancer. But the latter is rarely a 
disease of early life, and when of such early occurrence never per- 
sists to adult years ; while lupus is such exactly in the vast majority 
of all cases. The nodules of lupus are absent in epithelioma, and 
the evolution of the disease slower, less painful, and, in its earlier 
periods certainly, of deeper situation. The ulcer of epithelioma is 
more often defined and single; its edges whitish, indurated, and 
everted ; its floor uneven and glazed ; its secretion scanty and occa- 
sionally fetid ; its base a mass of indurated tissue. Lupous ulcers 
are often ill-defined and multiple ; their edges, soft and incon- 
spicuous, neither everted nor undermined ; their floors granulating 
aud flattened ; their secretion relatively profuse and generally odor- 
less ; their bases soft and pliable, though occasionally indurated. 

Tubercular, serpiginous, and ulcerative lesions of syphilis may at 
times resemble certain forms of lupus. In any doubtful case a history 
of infection, of other types of cutaneous disease, of mucous patches, of 
adenopathy, of abortions in the female, etc., should aid in the recog- 



LUPUS VULGARIS. 485 

nition of syphilis. The suspected lesions should be carefully ex- 
amined for the purpose of distinguishing characteristic lupous nodules 
in the patch itself or in the periphery of any exfoliating area. In the 
case of an adult, a long history of lupus can be often obtained; and 
it is worthy of note that syphilis with exceeding rarity displays for 
long periods of time a single exanthematous lesion or aggregation of 
such lesions in one part of the body exclusively. The lupous ulcers, 
often multiple and isolated, insensitive, rarely of well determined 
outline, never reniform or horse-shoe shaped, with supple, low edges 
and reddish, smooth, hsemorrhagic granulating floor, covered with 
crusts like soiled parchment of uniform thickness, do not resemble 
those of syphilis. The latter are often painful, single, circular, and 
clean-cut in contour, with firm, raised, infiltrated margins, and with 
offensive greenish and blackish crusts, resembling oyster shells. The 
cicatrices of syphilis are elegant, smooth, delicate, superficial, cir- 
cular, and, after pigmentation has disappeared, dead-white in color. 
Those of lupus are irregular, indurated, deforming, yellowish-white, 
and reddish-yellow. 

Acquired syphilis is a disease of adult life ; lupus begins in 
childhood. 

The disks of psoriasis are distinguished from flat exfoliating 
patches of lupus vulgaris by the relatively large number of the 
former, the nacreous lustre of the scales, the reddish hemorrhagic 
surface beneath, and the sites of election of the disks, usually on the 
extensor faces of the limbs. 

Lupus erythematosus is even more readily distinguished by its 
characteristics ; including the absence of nodules, ulcers, and crusts, 
the superficial character of the disease process, the scaliness, and 
occasional symmetry of the patch. Cases are described of interme- 
diate forms between lupus erythematosus and lupus vulgaris, but I 
have never been able to persuade myself that these really occur. The 
two diseases, unfortunately somewhat similar in name, are unques- 
tionably distinct in character. The so-called intermediate forms 
shown to me have been in every instance cases of flat and scaling 
epitheliomatous infiltrations going on to ulceration. 

In acne and rosacea with a bulbous condition of the tip of the 
nose, the redness is vivid; and the telangiectasia complications with 
the seborrhoeic flux, are conspicuous points of difference from lupus 
vulgaris. There is further no ulceration nor scarring, and the patients 
have usually suffered from the disease ouly after arriving at maturity 
of life. The mucous surfaces are also spared. 

Lupus of the Face. — Here the first manifestations are the so- 
called primary efflorescences, exhibited on one or both cheeks, nose, 
or cheek and nose, as a dull-colored maculation, or minute nodule, 
often long unnoticed, or a finger-nail sized, purplish thickening of 
the skin. Extension may then occur by multiplication of lesions, or 
by spreading of the single patch, the central parts wasting or cica- 
trizing. The contracture of the irregular scars thus resulting may 



486 DISEASES OF THE SKIN. 

produce au ectropion of the lid or lip, and with this is often seen 
the " bouffissure" of the features already described. Crusting and 
ulceration may be conspicuous or well nigh absent features. Gradu- 
ally the subcutaneous tissue becomes involved. 

The nose, as already stated, may, after absorption of the lupous 
tissue, become shrunken and retracted to a miniature of its former 
dimensions, its tip being noticeably reduced to a sharp poiut. In 
other cases (one such is now under the author's care), the point 
becomes bulbous, flattened, livid, and knobbed, with a thickened 
septum and distorted alse, an isolated patch or two of lupus infiltra- 
tion showing in the neighborhood of the cheek on one or both sides. 
The last described condition may lead by degenerative processes to 
the first, but is more commonly noticed as a less severe and more 
localized involvement of the face which may terminate, in favorable 
cases, without the severe mutilation first described. 

The upper lip, when involved, becomes first swollen, fissured, 
hemorrhagic, and crusted, aud a granulating surface indicates exten- 
sion of the disease to the adjacent mucous surface. Later, if the 
ulcer heal, the mouth, by contracture, is reduced to a repulsive 
looking slit or chasm in the face, permanently retracted, aud either 
open or closed. The gums, lining membraue of the lips, velum, and 
hard palate may be also granulating, eroded, or whitish, when the 
exfoliated epithelium is in situ. Ulceration and cicatrization here 
also produce deformities interfering with the function of the parts, 
aphonia, for example, resulting from the operation of these causes in 
the larynx. 

Lupus Vulgaris of the Ears may be symmetrical in develop- 
ment, or affect but one auricle. As in eczema, a favorite point of 
election is the lobule, which, with or without tumefaction of the 
whole organ, becomes a pyriform, purplish, dependent tumor, 
agglutinated speedily to the cheek. Later, when ulceration occurs, 
the auricle may disappear, or be reduced to a shrunken shell of its 
former state, the external auditory meatus being, by the same process, 
occluded. 

Lupus of the Trunk is, as a rule, more extensive and less 
destructive than lupus of other parts. Giant areas over the loins, 
hips, and belly may be involved in superficial serpiginous ulceration, 
the centre healing as the peripheral ring spreads. In these cases, it 
is even more difficult than in others to insure cicatrization. 

Lupus of the Genital Region may occur in both sexes ; aud 
then, as a rule, has extended thither from affected areas of the adjacent 
integument. "Lupus of the genital region" in women, so called, 
beginning in adult years, and strictly limited to incoercible ulceration 
of the mucous surfaces without marked involvement of the groins, 
pubic region, or cutaneous surface of the labia, is usually syphilitic 
in origin. 



LUPUS VULGARIS. 487 

Lupus of the Extremities is remarkable for its interference 
with the mobility of the smaller bones of the hands and feet, as a result 
of rigid cicatrices ; and also for the production of caries and osseous 
necrosis. Mutilating effects are thus produced by loss of phalanges, 
and also by shortening of the hand or foot after destruction of cen- 
trally situated bone. Elephantiasic enlargements of such organs as 
the hands and feet thus correspond to the livid tumefaction seen occa- 
sionally in the face. Thickenings, ridges, knobs, nodules, warty 
excrescences, ulcers, crusts, and callosities are often commingled, and 
in patients of mature years strongly resemble some forms of vege- 
tating and ulcerating epithelioma. 

Lupus of the Mucous Membranes means, for the most part, 
extension of the disease from an affected adjacent integument. The 
lupous nodule, in consequence of warmth and moisture, is here trans- 
formed into a moist papillary outgrowth, or externally granulating 
patch which may ulcerate and cicatrize. The borders of such an 
affected area are well defined, and its surface is of a dirty grayish- 
white color, where the investing epithelium is loosened but not yet 
detached. 

Treatment. — The internal treatment of lupus vulgaris is practically 
that indicated by the condition of the patient; inasmuch as no medi- 
cament is known to be capable, after ingestion, of relieving the victim 
of his local ailment. Of the articles in this category none will be 
more often indicated than cod-liver oil, the chalybeates, the bitters, 
the preparations of iodine, and possibly phosphorus. Arsenic and 
mercury are powerless to prevent the extension of the disease. With 
these, it is needless to add, a diet of the most generous character is to 
be supplied, and the rules of hygiene enforced. 

Iodoform and the iodide of potassium have been recently freshly 
recommended by Neisser, who employs the former in pills each con- 
taining half a grain (0.033). Thehypophosphites are useful in many 
cases. 

The local treatment of lupus vulgaris by the aid of parasiticides is 
based upon the infectious character of the disease ; and in many cases 
is brilliantly successful. Dr. White, of Boston, 1 with a view to its 
parasitic action, applies to the lupous patches rags soaked in solutions 
of the bichloride of mercury, one to two grains to the ounce (0.066- 
0.133 to 32.), and also applies ointments containing the same quantity 
of metal in the ounce of salve-basis. The favorable results obtained 
by him have been again and again verified by the author, who is in 
the habit of freely painting lupous ulcers with a solution of corrosive 
sublimate in the tincture of benzoin of the strength named. Salicylic 
acid two to four per cent, solution in castor oil and in ointments, half 
to one drachm to the ounce (2.-4. to 32.) ; sulphurous acid (Hutch- 
inson) ; .pyrogallol (Neisser) in ten per cent, ointments, spread on 

1 Boston Med. and Sugical Journ., October 29, 1885 



488 DISEASES OF THE SKIX. 

linen rags and covered with impermeable tissue; and iodoform, have 
all been successfully employed with the same object in view. [^i'lM 

.V modification of the Dubini-Volkmann method (that namely by 
multiple linear scarification) deserves mention here, as it is claimed 
with some justice to have changed the prognosis of the disease. It is 
somewhat doubtful whether anything is to be gained by either a pre- 
liminary freezing of the part, or the use of the cutting instrument of 
niauy blades devised by Squire, of which mention is made in the 
preceding article. The incisions are best produced with a delicate 
bistoury held in the fingers like a pen. They should be in parallel 
lines, closely set together, and crossed ; should extend completely 
through the depth of the lupous growth ; and this is determinable 
after some practice by the cessation of the creaking resistance which 
the blade fails to discover in normal tissue. Further, they should 
extend laterally beyond the borders of the lupous patch into the 
sound peripheral zoue. The bleeding is trifling, and readily arrested 
by firmly pressing small pieces of fine sponge, lint, or absorbent 
cotton over the part. The edges of the incision unite either by granu- 
lation or first intention ; and in both cases seem to serve as starting- 
points of the reparative process, the material for which, as already 
pointed out, seems to be supplied from the lupous nests themselves. 
Subsequent operations, when needed, require a previous freezing of 
the affected surface. 

Less efficacious, more painful, and much more disfiguring in its 
results, is the method of erasion by the dermal curette. This instru- 
ment is a sharp-edged spoon with a fenestrum in the bowl to permit 
escape of the debris. With it, the frozen lupous growth may be 
completely scraped away, and, if necessary, caustics subsequently 
applied. The method of treatment by multiple punctures instead of 
incisions is efficacious, though less satisfactory. Schiff, 1 and Auspitz, 
have combined puncture with the introduction of iodized glycerine 
(one part of the former to twenty of the latter), the first named 
operator using a tubular needle filled from a rubber pipette. 

The author has on several occasions, both in public aud private, 
employed the Paquelin knife without anaesthesia and with good results. 
The finer blades, especially manufactured for the purpose, are thrust 
at a red heat again and again through the lupous tissue until it is 
destroyed in its depth. Over the whole, the lower blade is firmly 
passed and pressed, the blackish coal resulting being the best subse- 
quent dressing after the serous exudation ceases. Americans are 
generally credited, abroad, with a preference for erasion followed by 
the galvano- or thermo-cautery. 

Treatment by chemical cauterization alone is now somewhat obso- 
lete. The various acids and alkalies, Cosine's paste, nitrate of silver, 
arsenical, mercurial, and zinc compounds, have all been thus em- 
ployed, and each, in suitably selected cases, may be productive of 
fairly satisfactory results. 

For the cases which do not require surgical or other operative 

i Vierteljhsft. f. Derm. u. Syph., Xos. 2 and 3, 1880. 



SCROFULODERMA. 489 

interference, simple local applications may be made, such as oily and 
fatty substances for the softening of crusts ; stimulating dressings of 
tar, iodated glycerine, thymol, ichthyol, carbolized glycerine, iodized 
phenol, naphthol, chrysarobin, and iodoform ; as also the carbolated 
unguents appropriate for the reparative phases of the ulcer left after 
the destruction of the lupous growth. 

The author's dernier ressort in the local management of ulcerative 
and rebellious forms of lupus vulgaris is creasote. It is applied with 
a brush in a pure state ; is exceedingly painful, and often followed 
by uncomfortable reactive effects. It should be applied only by the 
practitioner. Cicatrization of exceedingly indolent and obstinate 
ulcers has followed this application. 

Bartarelli applies, in similar cases, equal parts of resorcin and vase- 
line. Gerhardt, 1 of Berlin, claims to have had good results in the 
local management of lupus by the use of ice-bags. Gartner and 
Lustgarten 2 claim to have better results in the employment of electro- 
lysis in lupus, by using as an electrode a flat silver plate attached to 
the negative pole of the battery, the plate being set in a hard rubber 
ring. They employ a current of from five to eight millamperes. 

Prognosis. — The future of most lupous patients treated with skill 
and in this country is quite satisfactory. Generalized tuberculosis or 
cachexia may complicate a small proportion of cases. The local 
process may result in grave deformity or disfigurement. But even 
in cases where this last issue seems of severest grade, if there be no 
recurrence of lupous nodules in the cicatrix, the latter, in course of 
time, becomes less and less conspicuous. One of the author's patients 
affected with disfiguring ectropion which several distinguished oculists 
failed to relieve by operative interference, completely disguised his 
deformity by the aid of a flesh-tinted silver plate covering the lid, 
and fastened by the aid of a slender arm to the bridge of a pair of 
spectacles. 

Scrofuloderma. 

Lat. scrofa, a sow. 

Scrofuloderma is an affection characterized by indolent hyperaemic, granu- 
lating, and degenerative changes in the skin and subcutaneous tissue, asso- 
ciated with adenopathy of the contiguous lymphatic ganglia, and otfen with 
other evidences of a systemic vice of nutrition. 

Symptoms. — The term Scrofula, or Struma, has been long and 
loosely applied in general medicine, for the purpose of designating a 
number of diseases whose real significance was unknown, and whose 
points of resemblance to each other were greatly outnumbered by 
their specific differences. The researches of the last twenty years 
have been steadily and continuously restricting this list, in almost 
every department of medicine. Many of the disorders once supposed 
to be scrofulous are now known to be syphilitic. Rickets, for 

i Medical Times, November 7, 1885. 

2 Wien. med. Wochenschrift, No?. 27 and 28, 1880. 



490 DISEASES OF THE SKIN. 

example, is properly recognized to-day as a manifestation of hereditary 
lues. In orthopaedic surgery, a number of joint affections once 
believed to be incontestably of strumous origin, are known to be 
producible by traumatism exclusively. And in dermatology, no less, 
a broad advance has been made since the day when eczema, psoriasis, 
aod acne were described as evidences of scrofula. 

It should, however, not be forgotten that there are few fast and 
hard lines in the economy of nature. The requirements of a scien- 
tific classification of diseases are often too rigid for the phenomena 
both of good and ill health. It cannot be questioned that the scrofu- 
lous may become both eczematous and psoriasic; that, in short, 
.struma may coexist with other diseases. 

The coexistence of cutaneous with other diseases proves nothing as 
to the essential character of either, or the relation of the one to the 
other. The author has at this moment in his charge two patients 
who have been psoriasic for years, each of whom has lately contracted 
syphilis, one with the addition of a blennorrhagia. The distinction 
between these disorders is admitted beyond a peradventure ; and yet 
when the strumous patient gets eczema, acne, or lupus, it is difficult 
and often impossible to establish in the mind of some observers the 
conviction that there is no essential connection or relation between 
these disorders. 

It is only by comparing such cases with the multitude of others 
where no such concomitance can be recognized, that a just estimate 
of the truth can be made. 

This much premised, it may be added that the term, scrofuloderma 
is here strictly limited to those cutaneous changes which occur in 
distinctly scrofulous subjects, and which are themselves stamped by 
the peculiar imprint of the disease. Billroth's description of the 
scrofulous diathesis may here be recalled. By this term he recognized 
that condition in which there occurs at any point in the body where 
irritation has been induced, an indolent inflammation wdiich persists 
after such irritation has ceased, which frequently terminates in sup- 
puration and caseification, and which subsequently rarely pursues an 
hyperplastic career. If with this be conjoined inflammation and 
caseous infiltration of the lymphatic ganglia or of the subcutaneous 
connective tissue ; amyloid degeneration of one or several of the 
viscera ; tumefaction of the belly ; chronic keratitis, ophthalmia, 
otorrhoea, or coryza ; a chronic arthritis (white swelling) ; a pasty, 
<lirty-colored and thick, or delicate and transparent skin exhibiting 
cicatrices of old abscesses or ulcers, the general picture of the scrofu- 
lous patient may be considered complete. 

The recognition by Robert Koch of the etiological importance of 
the bacillus tuberculosis in tuberculous disease, aud the demonstration 
of the presence of these microorganisms in a number of lesions hereto- 
fore regarded as " scrofulous," has produced no little uncertainty as 
to the dividing line between struma aud tuberculosis. Neisser, in the 
list often disorders described by him as both chronic and infectious, 
names tuberculosis as first, and under this as a generic title, places 



SCROFULODERMA. 491 

miliary tuberculosis of the skin, scrofuloderma, aud lupus vulgaris. 
Doutrelepont, Robinson, and a number of other authors regard these 
as related if not identical processes. The position assumed with 
regard to this question by Volkmanu 1 agrees both with the strict 
requirements of pathological demonstration and with clinical experi- 
ence. These disorders are identical as regards the bacillus, but 
different clinically. 

The scrofulodermata are all characterized by the occurrence of 
pathological processes in the skin which betray the evidence of the 
scrofulous process. They usually begin as subcutaneous nodules 
similar in type to the syphilitic gumma, which gradually become 
attached to the skin, subsequently degenerate, exhibit characteristic 
ulcers, and usually terminate by no less characteristic cicatrices. 

The typical scrofuloderm is encountered about the face and neck, 
where the lymphatic glands have long been tumid, and either dense 
or doughy to the touch. This condition is usually reached very 
slowly ; often months and years are required for its production. The 
glands may be as small as almonds or as large as the closed fist. 
Gradually a scrofulous dermatitis ensues in the skin which is super- 
imposed. It becomes purplish and thinned, and finally yields, giving 
exit to a sero-purulent fluid mingled with caseous matter and blood. 
The pus-corpuscles of this fluid, examined under the microscope, are 
seen to be poor in protoplasm. Fistulous tracts and sinuses result, 
which undermine and perforate the skin, resulting in the formation 
of a chronic discharge and characteristic ulcers. 

The latter are far more remarkable for their borders and bases 
than for their floors. They are usually linear, occasionally elongated 
and oval, almost never circular. As a result, their uneven floors, 
covered with pallid granulations and a watery pus, are often hidden 
beneath their inverted, tumid, and uncolored edges : or the latter 
may be thinned, stretched over a fistulous pocket, and reddish or 
purplish in color. Their bases are usually deeply attached to the 
subcutaneous tissues, and are firm or soft, never densely indurated. 
The resulting crusts are thin, tenacious, reddish or brownish, and, 
like the ulcer, often linear, rarely bulky, never rupioid. The result- 
ing cicatrices are corded, depressed in irregular lines or bands, and 
often alternate with equally irregular nodules (scrofulous gummata), 
where the degenerative process has been either arrested or is still in 
progress. 

Rarely, enormous ulcers originate in the manner described above, 
which dissect out vast areas of subcutaneous and intramuscular tissues 
in the neck or over the extremities, in the course of which cartilage, 
bone, and periosteum are melted away. Usually but a few of these 
points of degeneration, from two to six, are exhibited in one patient. 

The Papular Scrofuloderm (Lichen Scrofulosorum). 

This eruption, first described by Hebra, is characterized by its 
chronicity, and the occurrence chiefly upon the trunk, back, and 

1 See his remarks before the German Surgical Society, Fourteenth Congress. 



492 DISEASES OF THE SKIN. 

belly, of millet-seed to pin-head sized, firm, flat, light to livid red, 
and grouped papules. These are occasionally surmounted at the 
apex by a minute scale, rarely by an equally small pustule. The 
lesions are at the onset isolated; later, they tend to arrange them- 
selves in coin-sized patches ; when evolution is accomplished they 
are closely set together, the surface of the skin being then of a dirty 
reddish-brown color, and covered by thin scales which are readily 
detached. Often a crescentic outline can be determined in a group 
of aggregated lesions. 

The course of the eruption is slow ; often the cutaneous symptoms 
persist for months without apparent change, awaking little or no 
pruritus, and followed by involution, accompanied by slight desquam- 
ation and no cicatrices. 

In ninety-nine per cent, of all cases observed in Austria, there was 
concomitance of the geueral symptoms of struma named above (sub- 
maxillary, cervical, and axillary adenopathy, periostitis, ulcerative 
dermatitis, etc.), with frequent complications, such as eczema of the 
scrotum and acne cachecticorum. The disease was encountered in 
young strumous patients between the periods of infancy and puberty, 
never after the twentieth year. 

According to Kaposi, the disease consists in an exudative infiltra- 
tion of the pilo-sebaceous follicles and the perifollicular tissue. Each 
papule represents, therefore, the orifice of a follicle, with an infiltrated 
perifollicular annex ; and its apicial scale or pustule, a mass of 
epithelial debris, or the inflammatory exudate 

The disease is readily differentiated, by the absence of itching, 
from papular eczema. From the miliary papular syphiloderm it 
differs in that the lesions of the latter, even though grouped, are 
always individually distinct. The general symptoms, however, are 
strikingly different in the two diseases. Lichen scrofulosorum can- 
not be confounded with lichen planus or lichen ruber. Lichen pilaris, 
however, in a young and lymphatic patient, might readily be mis- 
taken for the disease in question. 

This scrofuloderm is rare in France, and has not yet been recog- 
nized in this country. 

The Small Pustular Scrofuloderm. 

This eruption has been described by Duhring 1 only. In the 
three patients whose cases are reported, there were disseminated pin- 
head and small split-pea sized, yellowish pustules, having a firm base 
and purulent contents visible on the extremities, especially over the 
hands and forearms. Their course was indolent. Corneous, yel- 
lowish, or gray-tinted crusts succeeded, leaving a marked " punched- 
out" scar. Relapses occurred, the entire process lasting for months 
and years. The general symptoms of struma were present in each 
case. The disease is to be distinguished from the small pustular 
syphiloderm, acne cachecticorum, and follicular lupus. Microscopic 

1 Trans. Am. Derm. Assoc , Fourth Annual Meeting, Chicago, 1881, p. 29. 



SCROFULODERMA. 493 

examinations of the lesions exhibited unmistakably a non-follicular 
origin of the disease. 

The Large Pustular Scrofuloderm 

is described by the same author as a rare eruption, constituted of 
large, roundish, flat pustules, with a deep red or violaceous areola. 
A thin, flat, brownish, and adherent crust partially or completely 
covers each lesion, after the desiccation of its yellowish contents, and 
beneath is found a shallow ulcer of the scrofulous type. One, two, 
or more lesions may exist, often over the sternum, where they leave 
superficial cicatrices. There is concomitance of the general symptoms 
of struma. 

Etiology. — Scrofula is a disease of both sexes and all races, usually 
developed in early life, and pathologically due to the presence of the 
bacillus tuberculosis, though its clinical phenomena differ from those 
exhibited both in tuberculosis of the skin and lupus vulgaris. 

All causes which tend to impair the nutrition and vigor of the 
body are, to an extent at least, efficient in its development, including 
privation from sunlight, fresh air, wholesome food, exercise, and 
hygienic influences in general. It is common among prisoners, 
exiles, and, in this country, among negroes and those of mixed 
blood. Consanguineous marriages are said to result often in 
strumous offspring. Syphilis, in the third and fourth generation, is 
known to be pathologically distinct from all of its manifestations. 
The question of the possibility of its production by inoculation and 
its transmission in a feeble degree by contagion is still unsolved, with 
the probabilities strongly in the affirmative. In many cases, it is 
the sequence of other depressing medical diseases and surgical acci- 
dents. In other cases, especially where it is limited to the neck, and 
accompanied merely by cervical or submaxillary adenopathy, it is 
consistent with full vigor and nutrition of the body and all other 
evidences of sound health. 

Diagnosis. — The disease is to be distinguished by its general 
physiognomy from syphilis, lupus, cancer, purpura scorbutica, and 
other diseases exhibiting cachectic symptoms. The early age at 
which it is commonly developed is usually significant. The site of 
the lesions, with their characteristic ulcerations, crusts, and cicatrices, 
are also distinguishing features. 

Treatment. — The general treatment of struma demands a generous 
supply of fresh air (especially that of the seashores abounding in 
kelp) ; a liberal animal diet, including an abundance of pure milk 
and cream; and the employment of cod-liver oil, iron, iodine, lime, 
phosphorus, and similar substances internally. The local treatment 
of the disease requires the employment of poultices, lotions, stimu- 
lating unguents, and disinfecting washes, with such surgical inter- 
ference as is demanded by the existence of pus-filled pockets, sinuses, 
and fistulous tracts. 



494 DISEASES OF THE SKIN. 

Prognosis. — The disease, when skilfully managed, is amenable to 
treatment. The strumous patient who survives puberty will, if sur- 
rounded by favorable circumstances, usually show fair health after- 
ward. The course of the malady is, however, always tedious. The 
prognosis may be said in general to be based upon the severity of the 
symptoms in early life. 

Tuberculosis of the Skin. 

This exceedingly rare manifestation of tuberculosis is usually first 
disclosed in indolent, circular, or oval superficial losses of substance 
in the skin, covered with crusts. The floor of each is a granulating, 
hemorrhagic, pale, reddish surface; its base is infiltrated, but 
supple; its edges are irregularly notched from the occurrence of suc- 
ceeding purulent foci about the original sore. They spread very 
slowly, and, though small, may coalesce. They usually occur about 
the mucous outlets. 

Tuberculosis of the skin, associated with or secondary to tubercu- 
lous foci in underlying tissues, is occasionally encountered. In this 
way, for example, in tubercular disease of the testis, the skin will 
become painful, tender, and of a livid hue, will become attached to 
the subcutaneous tissues, and finally yield, giving exit to a soft, 
caseous matter, mingled with pus. Wagner,' Weber, Vidal, and 
other authors have described similar changes. True tuberculosis of 
the skin proper is of exceedingly rare occurrence. Chiari and 
Jarisch have, however, reported such cases, one in a man forty- 
two years old, who had behind the left ear a reddish-yellow, cres- 
centic, granulating ulcer, with infiltrated borders and a number of 
degenerating miliary granulations upon the velum of the palate. 
Post-mortem, isolated and grouped, roundish nodules were discovered 
undergoing caseous degeneration. Spillman 2 gives several instances 
of tuberculization of the skin associated with pulmonary phthisis. 

Two cases of tuberculosis of the skin have been observed at 
Kaposi's clinic. 3 

The patients were aged respectively fifty-three and thirty-six years. 
In one, there were buccal, laryngeal, and tracheal ulcerations of 
tuberculous character, with an ulcer of the upper lip, occupying the 
entire space between the nose and the lip. The other patient pre- 
sented a coin-sized ulcer near the left ala nasi, and others on the lip 
and adjacent gum. In one of these patients, the lungs were intact, 
and the tuberculosis of the skin was primary. The other died of 
pulmonary phthisis; but in both there was intestinal tuberculosis. 
Microscopical examination of the cutaneous lesions disclosed nume- 
rous tubercles in the corium which had undergone caseous degenera- 
tion. In the centre of the mass, disseminated miliary nodules, 
transparent or light-yellow in color, were visible in the parts which 
had not undergone characteristic granulation. 

1 Diseases of the Testis, T B. Carting, F.R.S., London, 1878, p. 389. 

2 De la Tnberculation tin Tube Digestif, These de Paris, 1878. 

3 Deuts. Med. Zeit., Jan. 1882. 



SCROFULODERMA. 495 

There are several disorders of the skin, which may be very briefly 
considered in this connection, whose nature is obscure, and with re- 
gard to whose identity there may be some doubt. 

Ainhum. — This disease was first described by Dr. J. F. Da Silva 
Lima, 1 of Bahia, in Brazil. In a paper by this observer, which was 
read by me before the American Dermatological Association, in 1880, 2 
the disease was described as affecting usually the little toe of the 
negroes resident both in Africa and Brazil. An indurated ring 
encircled the root of the digit, which produced, finally, a deep, 
narrow, circular depression, the latter deepening till the toe was 
strangulated, and finally, in the course of from five to ten years, 
completely detached. Meantime, the volume of the digit was greatly 
increased by development of fatty tissue at the expense of the ten- 
dons, vascular elements, bones, and cartilages. 

This paper was accompanied by the presentation of a toe affected 
with ainhum; and the specimen was referred to a committee, who 
examined it with care, and reported the result of the examination by 
the succeeding year. The report, presented by Dr. Heitzmann, of 
New York, after giving a full description of the anatomical appear- 
ance of the specimen, suggested the probability that the constricting 
ring was produced artificially by tying a thin ligature around the toe, 
which, if not continuously encircling it, was worn at least for long 
periods of time. 

Duhring 3 also has published the report of a case of ainhum where 
microscopical examination of a toe which was cast off from the foot 
of a negro in West Virginia was made by Dr. Wile. The latter 
came to the conclusion in this case also that the disease was essen- 
tially an inflammatory oedema produced by ligating the toe. 

Podelcoma. — This disease, known as Madura Foot, Mycetoma, 
or the Fungous Foot of India, attacks generally the foot, though the 
hand also may be affected. Its beginning is insidious. The part 
becomes swollen, painless, and covered with pea-sized vesicles, bou- 
tons, or elevations, over which are dispersed minute blackish granules. 
Each tubercle surmounts a sinus, from which, after bursting, is 
discharged a thin, sero-purulent fluid, containing granules, separate 
or aggregated in yellowish-brown mulberry-like masses. The 
swelling gradually increases, till the foot is a misshapen organ, 
riddled with sinuses which perforate periosteum and bone. Then 
fistulous tracts discharge from time to time granules like poppy-seeds, 
caseous matters, or substances likened to blackish fish-roe. 

According to Carter, the disease depends upon the existence in the 
parts of a specific fungus, Chionyphe Carteri. The spread of this 
mycelium in the skin, subcutaneous tissue, and deeper parts produces 
the tubercular buttons which break down and ultimately lead to the 

1 In the Gazeta Mediea du Bahia, Nov. 13 and 15 1867. 

2 Arch, of Derm., October, 1880. 

3 Amer. Journ. of. the Med. Sci., Jan. 1884. 



496 DISEASES OF THE SKIN. 

sinuses described above. Some authors are incredu his, however, as 
to the mycotic nature of this affection: The disorder lias been studied 
by Vandyke Carter, Miuas, Moore, Christie, and other surgeous of 
India, a country where the disease has beeu prevalent. Tilbury Fox 
presented, at different times, two specimens of the disease to the 
London Pathological Society; and it is worthy of note that in Eng- 
land the black masses were not in every case discovered. Kemper 1 
has reported a similar case in this country. 

Prof. Chas. T. Parkes, of Chicago, has recently had under obser- 
vation a similar case, occurring in the person of a gentleman who 
had long been a resident of India. From the notes kindly furnished 
the author, it appears thai, after the occurrence of characteristic 
tubercles, an ulcer attacked the skin over the inner malleolus of the 
right ankle, and steadily increased in size and depth for a period of 
five years, in spite of all treatment. Sinuses extended deeply to the 
tissues beneath. The entire surface was covered by a peculiar, softish, 
light colored, fluffy material, corresponding to that described by 
several of the Indian observers. The general appearance of the 
disease was unlike any previously observed here. The entire surface 
was thoroughly scraped with a Simon's spoon, and dressed with a 
saturated solution of boric acid, after which repair ensued. 

Synovial Lesions of the Skin. — Under this title should be 
described certain strictly cutaneous lesions which possess some impor- 
tance from a diagnostic point of view. I have had the opportunity 
of observing these in several individuals, where the exact nature of 
the disorder had not been understood. They occur in the form of 
wart-like projections from the skin, pseudo- vesicles, and bulla?, 
always over the site of bursa? connected with tendons, traversing the 
small articulatious of the hand and foot. They are seen over the 
metatarso-phalangeal articulatious; and in the hand most frequently 
over the dorsal face of the articulation between the distal and adja- 
cent phalanges of the index and thumb. The first form is that of a 
roundish, corneous, pea-sized wart with a yellowish centre, of long 
duration, usually insensitive unless roughly handled. When punc- 
tured, a syrupy, yellowish, or grumous fluid exudes, and continues 
to form after repeated puncture. Split-pea sized vesicles, and bulla? 
as large as a silver fifty-cent piece, often exceedingly painful, are also 
seen, especially upon the feet, with simply an epidermic roof-wall. 
Each contains the same thickened, yellowish, or whitish fluid, occa- 
sionally mingled with masses like sago grains. In every case the 
contents of the lesion are supplied by a synovial bursa beneath the 
skin, with which the lesion is either directly connected, or in communi- 
cation by a short sinus. The treatment requires the complete excision 
or destruction of the secreting cyst-wall. 

Mr. Sidney Jones, and Mr. Makins, of St. Thomas's Hospital, have 
recently exhibited several lesions of this character to the London 
Pathological Society. 

i Amer Practitioner, Sept. 1876. 



SYPHILODEEMA. 497 

The Sartian Disease (Taschkent-geschwur) is an infectious 
granuloma, described by Heiman, 1 and examined microscopically by 
Rudniew. 

It occurs in Taschkent, affecting the face, upper extremities, and 
trunk, avoiding always the palmar aud plantar regions. Reddish 
maculae develop here into nodules, which desquamate, coalesce, 
degenerate, and leave crusted ulcers, which may cicatrize. 

Syphiloderma. 

Syphilis is a chronic infectious disease, transmitted by heredity, or by the 
medium of intoxicated blood or morbid secretions, capable of involving in 
its course any one of the organs and tissues of the body, whose manifesta- 
tions in the skin are termed syphilodermata. 

Syphilis is a disease not yet actually demonstrated to be produced 
by microorganisms, but whose position among the infectious granulo- 
mata is now almost established. It is true that Lustgarteu, Doutre- 
lepont, and others, have demonstrated the presence of bacilli 
resembling those found in tubercle, in papules, nodes, chancres, and 
secretions from syphilitic lesion ; but the strict requirements of 
science as to the proofs of etiological value in these particular germs 
have not yet been fullv satisfied with respect to this disease. 
Whether these microorganisms or others be finally demonstrated to 
be the potent agency in producing syphilis when it is transmitted by 
the medium of a virus, it is at least certain that the revelations made 
by late investigations into the nature of lepra, mycosis fungoides, and 
tuberculosis lend the very strongest support to the doctrine that the 
oontagium of syphilis is due to the presence in its secretions of a 
species of bacterium. 

Syphilis has been described by one writer as an " imitator of other 
diseases." Whatever exception it is proper to take to the doctrine 
implied by such a term, it is necessary to understand clearly of the 
manifestations of the disease that they are protean in character, and 
may occur in every organ and tissue of the body. These manifesta- 
tions are both like and unlike the symptoms of non-syphilitic disease 
of such organs aud tissues. It would be, therefore, more in accord- 
ance with facts to describe syphilis as a special mode of disease. Its 
phenomena differ from other pathological phenomena, chiefly in the 
syphilitic modality with which they are impressed. After infection 
there is a different behavior of the living matter or protoplasm of 
which the body is constituted. Its mode is thenceforward tempo- 
rarily changed, as regards the processes of disease. Hence the 
importance of recognizing this modality in relation to disease of the 
skin, and of ascertaining the limits within which this influence is both 
originated and exhausted. 

The skin manifestations of syphilis are of common occurrence ; 

1 Deutscb. med. Woch., No. 3, 1883. 
32 



498 DISEASES OF THE SKIN. 

numerous as to their forms, aud of the greatest importauce from the 
diagnostic standpoint. 

As in syphilis of other organs, that of the skin is betrayed in 
symptoms like and unlike those of non-syphilitic affectious. The 
study of these differences is here also a study of the syphilitic mode 
of disease. In a treatise of this scope aud within these limits, it will 
be proper to describe only those evidences of the syphilitic process to 
be recognized in the integument. The initial lesion of the malady 
occurring either on the mucous membrane or integument, requires 
brief consideration : 

Chancre. — A chancre is that modification of the sound or patho- 
logically altered skin or mucous membrane, preceded by a period of 
incubation, characterized by sclerosis, and accompanied by adenopathy, 
which constitutes the initial lesion of inevitable syphilis. 

Chancres usually appear upon or about the genital organs simply 
because those organs are most often exposed to the disease. They 
may, however, occur upon any portion of the surface of the body. 

They appear after a period of incubation, an interval of time 
between the date of exposure to the disease and the manifestation of 
its first symptom. This period averages in length twenty-one days, 
and may extend from ten days to two months and even more. 

The chancrous modification may, as stated above, involve the 
normal or pathologically altered skin or mucous membrane. Upon 
previously sound surfaces chancres may appear, after the incubative 
period, as maculse, papules, tubercles, erosions, fissures, or ulcers, each 
of which, at some future period of its history, is characterized by a 
peculiar hardness of the tissues about and beneath the lesion, this 
condition being known as the initial sclerosis. These symptoms vary 
according to the location of the lesion, and the friction or other 
external treatment to which it has been accidentally subjected. Gen- 
erally it may be said that they all tend to the papular type, the 
macule developing into that lesion, the tubercle being evolved from 
its exceptional enlargement, the ulcer from its degeneration, and the 
erosions or fissures from the accidents of its less pronounced features. 
Occurring upon mucous or quasi-mucous surfaces, these lesions are 
influenced by heat, moisture, and friction (labia, prepuce, etc.). Here 
the superficial erosions are usually circular in outliue, are very 
slightly depressed, and rest upon delicate beds of sclerosed tissue, the 
so-called parchment induration. The papule is often represented by 
a macular discoloration of the membrane, tolerably well circum- 
scribed, where coarse examination would scarcely suggest elevation of 
the surface, with a sclerosis of no greater extent than that of the 
erosion with which it probably sustains a close relation. As a result 
of heat, moisture, and friction, however, the typically dry and scaling 
papule constituting the chancre of the integument, is here rarely 
encountered. More often, the lesion is a circumscribed ulcer with 
clean-cut walls, penetrating deeply to the derma or even below it, 
with a scanty secretion and reddish floor, resting upon a split-pea 
sized mass of sclerosed tissue. Other usual forms are superficial 



SYPHILODERMA. 499 

erosions, in themselves of insignificant aspect, surmounting large 
nodules, tubercles, or even long linear ridges of densely sclerosed 
tissue, undergoing repair or degenerating according to the condition 
of the patient and the -treatment to which he has been subjected. 
These erosions are usually out of all proportion to the size of the 
indurated mass upon which they rest. Such voluminous indurations 
are occasionally perforated by deep conical or funnel-shaped ulcera- 
tions of formidable aspect, to which the name " Hunterian chancre " 
was once applied. 

Occurring upon cutaneous or mucous surfaces where there has been 
a previous pathological condition, the syphilitic mode is impressed 
upon the symptoms significant of such previous disease. This acci- 
dent is sufficiently common, and the resulting lesions as different as 
those of different diseases. Thus a man or woman may be infected 
with syphilis at the site of an herpetic vesicle upon the lip or genitals, 
such vesicle being unbroken and recent, or several days ruptured ; or 
at the site of a balanitis ; or of a vegetation ; or of the soft conta- 
gious sore of the genital region best recognized in America under the 
term " chancroid." Or the inoculation may occur at the site of a 
traumatism, as for example where the frenum is slightly torn in 
coitus, or where the bruised knuckle of the accoucheur is exposed 
during the practice of his art. 

The induration of chancres may precede, accompany, or follow the 
lesion with which they are associated. The sclerosis may be short- 
lived, persistent, or recurrent ; and in this respect resemble the 
chancre itself, which may endure for but a few days, or be in course 
of full evolution at the date of the appearance of the so-called 
secondary symptoms. 

With very rare exceptions, the ganglia in anatomical connection 
with the chancre become, as a consequence, enlarged and specifically 
indurated. With genital chancres there is usually double inguinal 
adenopathy ; with labial chancres, submaxillary adenopathy ; with 
chancres of the lid, pre-auricular adenopathy, etc. The glands usually 
eularge within a few days after the appearance of the chancre, and 
remaiu in that condition for several months afterward. They are 
indurated, on one or both sides of the body; are freely movable; are 
unattached to surrounding tissues; are neither painful, tender, nor 
inflammatory ; and hence neither terminate by suppuration nor 
ulceration. 

It will thus be evident that the word "chancre" is applicable only 
to certain features assumed by other lesions ; and is not itself descrip- 
tive of a lesion differing absolutely from all others. It is indeed 
clear that there can be no particular chancre lesion, since in turn the 
macule, vesicle, pustule, papule, tubercle, erosion, vegetation, ulcer, 
and fissure may each become a chancre. Every other elementary 
lesion of the skin, therefore, may assume the chancrous features, in 
other words, display in its disease-process the modality of syphilis. 
These chancrous features are : infection ; sclerosis after an ncubative 
period ; coincident or consequent adenopathy (sclerosis of neighboring 



500 DISEASES OF THE SKIN. 

ganglia) ; and, after a second incubative period, the occurrence of the 
symptoms of general syphilis. The last named is of course an 
historical feature, not recognizable during the greater part of the life 
of must chancres. 

Their minor features are less constant and trustworthy. Chancres 
of the skin are often deeply pigmented. Some are painful from the 
occurrence of inflammation. Some are injured by traumatism 
(chancres of nipple in nursing women); some, by irritants (caustic 
improperly applied); some finally are so insignificant iu feature 
(chancre of the vagina) that even the expert is readily deceived iu 
their recognition. 

With or without involution and complete disappearance of the 
chancre, the symptoms of general syphilis occur only after a second 
period of incubation. This extends usually from between the eud of 
the first to the end of the second month after the appearance of the 
chancre, the average being between the fortieth and forty-fifth days. 
During this period the general condition of the patient is one which, 
by subjective and objective phenomena, displays signals of the ap- 
proaching distress of the economy. There is anaemia and even in 
cases, chloro-amemia, wandering pains, substernal or about the articu- 
lations, a cachectic look, engorgement of the superficial and deep gan- 
glia, occasionally a well-marked febrile process, the so-called syphilitic 
fever, and, as Bumstead has shown, a special irritability of the skin 
and mucous membranes. 

At this momeut, the second period of incubation of the disease 
being completed, the patient is ready for an "explosion" of general 
syphilis. Iusidiously or suddenly, first noticed upon the skin beneath 
the clothing, with rapid efflorescence over the entire surface after a 
hot bath, the stimulus of liquor, or the excitement of the dance, 
appear the syphilodermata, or syphilides, the skin symptoms of 
syphilis. 

Syphilodermata. 

Lesions of the skin appear iu syphilitic individuals of both sexes, 
in all periods of life, and in all stages of the disease. They are, 
however, much more frequent during the first two years after infec- 
tion, subsequent to which period the symptoms of the disease are 
more commonly betrayed in subcutaneous lesions, or those which 
aifeet the viscera, the osseous, nervous, muscular, and vascular sys- 
tems. 

General Characteristics of the Syphilodermata. — The 
syphilodermata, like chancres, are, properly speaking, modalities of 
such symptoms as occur in diseases not syphilitic. The distinctive 
difference between the papules, ulcers, and other lesious of syphilis 
and lupus for example, is a difference chiefly in their mode of evolu- 
tion and involution. It is the syphilitic behavior, rather than the 
syphilitic lesion, which guides the diagnostician to his end. The 
syphilides, in short, resemble in their lesions most of the other diseases 



SYFHILODERjf A. 501 

of the skill, and differ also in various degrees from each one of the 
latter. Hence is seen the importance of a clear recognition of their 
general characteristics : 

Absence of subjective sensation. — The eruptions produced by 
syphilis are rarely attended by itching, burning, or painful sensa- 
tions of any sort. This is frequently a positive aid in establishing a 
diagnosis, and, as a rule, is the more valuable the graver the lesion. 
Great difference, however, will be noted in this respect between 
different individuals. Occasionally considerable itching will be per- 
ceived, and syphilitic ulcers, especially of the leg, will be productive 
of severe pain. At the same time, it is a common experience to find 
a patient quite tranquil as regards all subjective symptoms, covered 
from head to foot with a brilliant macular syphiloderm, or exhibiting, 
with the utmost composure, an enormous number of serpiginous 
ulcerations on his scalp and extremities. 

Polymorphism, multiformity of lesions, a term used to designate 
the coincident appearance of lesions of various types upon one indi- 
vidual, is true of syphilis as of other diseases such as lepra and 
scabies. Viewing the cutaneous and other lesions of syphilis as a 
whole, this feature is strikingly significant, as it is possible to observe 
at one and the same time upon the person of a single infected indi- 
vidual, symptoms indicative of pathological changes in the skin, 
mucous membranes, hair, nails, lymphatic glands, and periosteum. 

To a less marked degree, this is true of the syphiloderm ata. The 
type of the syphilitic skin lesion is generally papular ; and such 
lesions may originate from macules, enlarge into tubercles, or degen- 
erate into ulcers. The simultaneous coexistence of several of these 
forms is often due, as Bumstead aud Taylor have well shown, to 
their chronicity, their tendency to recurrence, and the changes which 
they undergo. 

Career. — The historical course of the syphilides suggests certain 
common features. They are rarely accompanied by local inflamma- 
tion, and with the exception of the syphilitic fever, are usually 
unattended with pyrexia or malaise. The tolerance by the general 
economy of an extensively developed syphiloderm, is highly significant 
of the disease. Again, syphilis, though generally described as a 
chronic disease, is, judged from the standpoint of time merely, much 
more acute than several others. The syphilides have a distinct 
career, pursuing, even when untreated, a natural process of evolution 
and involution. Few, save those upon the lower extremities where 
the force of gravity is an important element in the fixation of all 
local disease, persist in unvarying type for any lengthened period of 
time. One lesion is apt to succeed another by development or 
degeneration ; and many of the untreated syphilides disappear without 
leaving relics of their existence upon the surface of the skin. In 
these last named particulars, syphilitic cutaneous manifestations are 
singularly different from lupus and carcinoma, for example, where 
the lesion is usually of one type, and persists in one location for a 
long period of time, during which the syphilide which it resembles 



502 DISEASES OF THE SKIN. 

would have progressed either to much more extensive damage or 
permanent repair. 

( 'nhr. — There is no color peculiar to the syphilodermata, which 
may not be seen in other diseases of the skin. It is important to 
recognize the fact clearly, as there are those who claim to diagnosti- 
cate the syphilides by their hue alone. The color, however, consid- 
ered in connection with the other features of the syphilides, is highly 
characteristic, and often sufficient to enable one at a glance to identify 
the nature of the disease. These color shades are usually less bril- 
liant than those seen in other cutaneous diseases, and possess less of 
tin scarlet and crimson quality. They are admixtures of red, yellow, 
and brown, in various proportions, with a frequent slight preponder- 
ance of the brown. They have been compared to the color of raw 
ham and copper, terms which have been unfortunately so associated 
with the hue of the syphilides, that the non-recognition of such 
peculiarity has led to many errors in diagnosis. Pigmentations, in 
various shades of chocolate, coffee, and black, are recognized amoug 
the syphilides both during their evolution and after completion of 
their involution. The process, as in cases where there has been no 
luetic affectiou, is here also due to increase of the pigment in the 
part, both with and without the extravasation of blood. Recent 
syphilitic scars are usually pigmented both in centre and periphery. 
Here also it is not so much the color, as the scar with the color which 
gives special significance to such lesion-relics. 

( 'ontour. — The contour of single elementary cutaneous lesions in 
syphilis as also of a group of aggregated lesions, is usually either 
circular, or has a distinct tendency to assume such a configuration. 
Thus it is common to find outlines of patches, ulcers, and scars 
observing the curve of a segment of a circle; and coalescence of 
several such tends to produce the serpiginous aspect. The earlier 
exanthems of syphilis are usually symmetrical; the later, asym- 
metrical. Even the symmetrically distributed eruptions will at times 
occur in annular patches, made up of maculo-papular lesions arranged 
in a circular or crescentic line. Patches of syphilitic eruption will 
often clear up at the centre and develop or spread at the circumfer- 
ence of a circle. 

Site. — No portion of the integument is free from the possibility 
of invasion by syphilis. It may involve at once almost the entire 
integument, or spread rapidly from point to point, having covered 
finally a large area, or appear conspicuously at distant and isolated 
points of limited extent, or, finally, be exclusively manifested in an 
insignificant lesion or group of lesions, ephemeral in course, and 
limited to one portion of the body. 

The site of a syphilitic eruption may be determined apparently 
by the capriciousness of the disease, and yet result from local irrita- 
tion of the skin of infected individuals. The accumulations on 
the napkin of women invite the occurrence of labial condylomata; 
the lips of the infant, after contact with the nipple of the mother, 
become the seat of rhaeades and fissures: while the tongue of the 



SYPHILODERMA. 



503 



tobacco-chewer and the fauces of the tobacco-smoker acknowledge 
similar sources of mischief. 

There are some sites of preference for special lesions, as, for 
example, the squamous syphiloderm of the palms and soles, and the 
papules of the forehead, constituting the so-called "corona veneris." 

Amenability to treatment. — Mercury possesses a singular influence 
upon the syphilodermata, which is promptly perceived when the 
drug is administered internally. This singularity rests upon the 
broad fact that the lesions of most other cutaneous diseases not only 
refuse to acknowledge the benefit of such medication, but in many 
•cases are aggravated by it. The importance of clearly recognizing the 
character of each cutaneous disorder submitted to treatment is thus 
well illustrated. 

Fro. fi2. 





Facial cicatrices of tubercular syphilodermata alter twenty-five years of infection. (From a 
photograph of one of the author's patients.) 



Characters of certain 'particular lesions. — Certain families of lesions 
in syphilis exhibit characteristic features. Thus some papular lesions 
are surrounded at the base by a peculiar fraying of the epidermis, 
in consequence of which they are encircled by a little fringe of 
scales resembling a collar. The scales' of syphilis are usually 
not abundant, but fine, dirty-whitish in color, or occasionally brown- 
ish. The crusts of syphilis are apt to be bulky, greeuish-black in 
hue, and to surmount secreting ulcers of various depths. Such 
ulcers are generally circular, or exhibit in contour a tendency to 



504 DISEASES OF THE SKIN. 

assume the circular line, while the cicatrices by which they are suc- 
ceeded have a similar configuration. The scars of syphilis are fre- 
quently smooth, delicate, very slightly depressed, unattached to sub- 
jacent tissues, and pigmented. Lastly, from several of the secreting 
lesions of syphilis, especially those upon and about the ano-genital 
region, proceeds a discharge having an offensive odor, and capable of 
communicating the disease to a sound individual by inoculation. 

Syphiloderma Maculosum. 

The cutaneous lesions of syphilis, limited to color changes in 
more or less circumscribed areas of the skin, are exhibited in two 
distinct forms, due respectively to anomalies in blood and pigment 
distribution. 

(a.) The Macular Syphiloderm due to Hyperemia is 
termed by several authors the Erythematous Syphilide, or 
SYPHILITIC Roseola. It is the earliest expression of cutaneous 
syphilis, and is more or less constant in occurrence, differing in this 
respect from several of the other syphilides. It is often unnoticed 
by the patient, whose attention may be first called to it after its 
recognition by the skilled eye of another. It occurs in coffee-bean 
to filbert-sized macula?, roundish, oval-shaped, or of irregular contour, 
varying in color from a light rosy to a dull mulberry hue. In some 
cases, these markings of the surface are very indistinct, requiring for 
their recognition the closest scrutiny in a clear light, and occasionally 
even then leaving uncertainty in the mind of the expert. At times, 
they constitute an irregular " marbling" of the surface, of a kind 
which renders it difficult to define with the eye the individual lesions 
of which the eruption is composed, while the general visual effect of 
the exanthem is exceedingly distinct. They are not elevated above 
the general level of the integument, but may change in type, a 
papular lesion developing later in the same site. 

Like all maculae of the skin due to vascular changes, they vary in 
color with the complexion of the individual, with the time which 
elapses after their first appearance, and with vascular changes in the 
superficial plexus of bloodvessels. Thus the deeper shades are 
usually observed in thick and muddy-tinted skins; the more delicate 
upon the breast, for example, of blonde women. The eruption 
usually appears between the sixth and eighth week after the appear- 
ance of the initial sclerosis, and, when untreated, develops for about 
one week more. It persists for a variable period of time, depending 
upon the severity of the constitutional disorder and the treatment to 
which the patient is subjected. During the early part of this time, 
the hue of the lesions is lighter, and they may be made to disappear 
under pressure; later, they are more deeply stained, and, exudation 
having occurred, the color of the spot does not disappear under the 
finger. When involution is in progress, there is slow disappearance 
of all symptoms of the eruption, which fades gradually from view. 



SYPHILODBRMA. 505 

The vascular changes in the capillaries, occasioned by cold, heat, and 
rapid cardiac contractions, all influence the eruption to a marked 
degree. A hot bath, a dance, a glass of spirits, a fit of excessive 
coughing, laughter, etc., may all bring the lesions into prominence. 

The eruption may be limited to the skin of the belly, extending 
also sparsely over the chest, loins, ano-genital region, and thighs, the 
palms, soles, forearms, and legs, or, in exceptional cases, profusely 
cover the entire surface of the body, face, ears, dorsal surfaces of the 
hands and feet, and skin of the penis with the progenital region. In 
the milder forms, it is evidently susceptible to external irritation of 
the skin, as it is common at the wrists where a starched cuff is worn, 
over the brow in the line covered by the hat-band, and particularly 
well developed in men where the trousers are " reinforced" (peri- 
neum and inner faces of the thighs). 

At times, as in the exanthematous fevers, the eruption is preceded 
by a febrile state with marked amelioration of symptoms when the 
rash is fully developed ; while again it is throughout accompanied 
by slight rise in the temperature, the patient having the so-called 
" bilious" appearance, muddy complexion, coated tongue, icteroid 
hue of conjunctivae, and offensive condition of the breath. Wan- 
dering pains in the extremities, and especially beneath the sternum, 
are frequently experienced. The last mentioned is highly significant, 
and the whole is probably clue to the effect upon the nervous system 
of the circulation of the recently intoxicated blood. These pains are 
not those produced later in periosteal and other complications of the 
disease, and are the more significant as the eruption itself is produc- 
tive of a scarcely appreciable subjective sensation. The superficial 
ganglia of the body are usually engorged at the same time; the 
fauces congested ; the hairs of the scalp slightly loosened in their 
follicles, and, in the latter region, in severe cases, papules and pus- 
tules may form. Inasmuch as the order of sequence of phenomena 
in syphilis is subject to a singular inversion, it occasionally happens 
that there is concomitance of later signs of the disease, such as iritis, 
affection of the nails and bones, or even, in places, pustular, papular, 
and squamous syphilodermata. 

Much less rare is the survival of the initial sclerosis to the date of 
this efflorescence. This is a point of considerable importance. The 
physician should never conclude the examination of a patient com- 
plaining of suspicious genital lesions without carefully exploring the 
surface of the trunk, and also never pronounce upon an exanthem of 
this sort without minute inspection and palpation of the part where 
an initial sclerosis may exist. In a diagnostic and therapeutic sense, 
the information thus gained may be precious, and in a large propor- 
tion of all cases is of a kind quite hidden from the knowledge of the 
patient. 

Relapses occur in certain cases with limitation of the disease to 
parts previously affected or unaffected. At the end of the first twelve- 
month, recrudescence of larger macula in annular groups may occur. 
Exceptional forms are noted where darker puncta appear in the 



506 DISEASES OF THE SKIN. 

macular lesion, occasionally traversed by a hair. These are localiza- 
tions of a more intensely hypersemic or exudative condition about 
the orifices of the ducts of the follicles. 

The diagnosis of this syphiloderm is readily established, in view 
<»f its essentially symptomatic character. From scarlatina, measles, 
and rotheln, it diners in the indolence of the rash, the absence of 
decided elevation of temperature, and the order of its appearance in 
different portions of the body, as it rarely occurs first upon the face. 
Urticaria and the rashes induced by the ingestion of copaiba and 
other medicaments, are distinguished by the marked itching of the 
surface and their very general diffusion over the entire body rarely 
observed in the syphiloderm. Tinea versicolor, usually limited to 
the anterior surface of the trunk, is characterized by a fawn to 
chocolate tinted color, by the existence of the readily recognized 
vegetable parasite beneath the scales scraped from the surface, and by 
the furfuraceous desquamation which the patient usually describes as 
most noticeable after a hot bath. It is, moreover, of much longer 
duration. Ringworm of the skin of the body is not symmetrical, 
and is also a parasitic disease. 

All these distinctions, however, are not to be compared for a 
moment in their diagnostic value, with the concomitant symptoms of 
syphilis, which are very generally present, such as adenopathy, per- 
sistence of the initial sclerosis, and evident involvement of other than 
cutaneous tissues. 

Such concomitant symptoms will be found occasionally with a 
non-syphilitic eruption due to drugs ingested for relief of the infec- 
tious disease. The most common of these is the iodide of potas- 
sium ; and the eruptions it produces are frequently found both com- 
mingled with the macular syphiloderm and occurring on the eve of 
the appearance of the latter. The existence of acneiform lesions 
upon the face, neck; and posterior surface of the trunk, a vivid 
erythema of the forearms including the hands, and purpura-like 
maculatious of the face, legs, and feet, should never mislead the 
physician as to the character of the disorder with which he is con- 
fronted. It is undeveloped syphilis with a dermatitis medicamentosa 
of the surface. Suspension of the iodide, which fortunately is not 
required in the immense majority of all such cases ; the use of a 
properly selected mercurial, or even (and this is often wise) absten- 
tion from all medication, will be succeeded by disappearance of the 
cutaneous lesions, which may be followed later by a mild macular 
syphiloderm, altogether insignificant in comparison with the eruption 
artificially induced. 

(b.) The second form of Syphiloderma Maculosum is that 
due to Anomalous Distribution of Pigment, described by 
authors under the title of the Pigmentary Syphilide. The erup- 
tion, if such it may be called, is occasioned by the appearance upon 
the surface, of irregularly circular, usually poorly defined, dirty 
brown and chocolate tinted maculae which, as they are entirely 



SYPHILODERMA. 507 

unconnected with vascular changes, do not disappear under pressure. 
The lesions occur as sparse and well isolated discolorations or, more 
commonly, as forming by a species of confluence an irregular rete or 
network, with relatively large interspaces characterized by an absence 
of such color. The eruption -is most common upon the sides of the 
neck especially in blonde women, though it may more rarely involve 
the surface of the trunk and the extremities. It is also most fre- 
quent during the first year after infection, though it may develop 
later. 

According to Fox, of New York, the color changes observed in 
the skin are explained by the occurrence : first, of pigmentary deposit 
chiefly at the centre of the ordinary macular or papular syphiloderm ; 
second, of peripheral absorption of such pigment with possible per- 
sistence at the centre of the lesion for a variable time; third, of total 
absorption of all pigment from the original lesion ; and lastly, of 
peripheral hyperpigmentation of the spaces intermediate between the 
original maculse. 

The eruption is regarded by some observers as an epiphenomenon 
of the syphilitic process, being not amenable to the treatment under 
which other macular syphilodermata speedily disappear. It is of 
rare occurrence ; and in the cases where I have had the opportunity 
of studying its features, seemed to be an expression rather of general 
deterioration of the health of the skin than of specific disease. 1 

It is liable to be mistaken for that condition in which there is 
simply an accumulation upon a somewhat greasy skin, of secretions 
and dust, to be seen upon the integument long unwashed. Tinea 
versicolor has a more yellowish or fawn-colored tint, and is more 
abundantly developed upon the front of the chest than the neck. 
Neither chloasma, vitiligo, nor leucoderma are symmetrically dis- 
posed, as is usually the pigmentary macular syphiloderm. 

Syphiloderma Papillosum. 

The type of all cutaneous lesions produced by syphilis, is to be 
recognized in the papule. Most of the others are either developed 
from it, transformed to it, or by reversion or admixture, confess that 
the neoplasm of syphilis in the skin is essentially a more or less solid 
circumscribed cutaneous lesion, varying as to size and history. 

Papules, occurring in syphilis, may appear as the first cutaneous 
evidence of infection, or may be developed from earlier maculse. 
They may be small, acuminate, flat, large, disseminated, or in groups. 

Small Acuminate Papular Syphiloderm. — In this eruption 
the lesions are recognized as millet- to hemp-seed sized, circumscribed, 
globular, acuminate, reddish, and salmon-reddish, firm elevations of 
the surface, or minute nodules upon the skin, generally symmetrically 

1 The author has seen this eruption most perfectly developed upon the skin of Chinese patients 
affected with syphilis. 



508 



DISEASES OF THE SKIN. 



developed, often over the entire body, closely set together, and occa- 
sionally grouped in crescentic figures. When viewed with care, a 
minute vesicle, pustule, or scale may be often detected at the conical 
apex of each lesion, which rarely develops to such au extent as to 
become a characteristic feature of the eruption. The color is at first, 
especially in blonde skins, a species of salmon and red. mixed; later, 
the darker and browner shades appear. When generalized, the erup- 
tion is well developed, especially over the posterior face of the body, 
the occipitocervical and scapular regions, the buttocks and calves of 

Fig. 63. 




Syphiloderma papillosum. (After Jcllien.) 



the legs, though it is often distinct about the anus and genitalia. 
Like several other of the syphilodermata, its earlier are more sym- 
metrical than its later manifestations, whether these be tardy, or 
relapsing, or both. The involution occurs by resorption of the plastic 
exudate, minute and usually scanty, dirty-whitish, colored scales 
encircling the base of each lesion. When the eruption has proved 
especially persistent, marked pigmentation follows in the form of 
brownish-red blotches, the centre of each of which displays a cicatri- 
form relic in the form of a punctum. 

The eruption is often first noticed about the forehead, nose, mouth, 
and neck, localities commonly subject to topical irritation. Thus 
about the forehead in men, the papules will be frequently arranged 
along the band pressed by the lining of the hat ; and the frequent 
lingering of the face, shaving, and irritation bv the edge of the collar 



SYPHILODERMA. 509 

of the shirt, may determine a more speedy efflorescence in the sites of 
.contact. About the month, tobacco plays the part of an excitant; 
and about the nose, a localized seborrhoea may be added to the syphi- 
litic phenomena, in which case the lesions may be covered with thin 
greasy crusts. The eruption is common during the first six months 
after infection, and is usully fully developed after a fortnight when 
no treatment has influenced its evolution. When the lesions are per- 
forated by hairs, they suggest, on superficial examination, a resem- 
blance to lichen pilaris, and when aggregated in patches of distinct 
oontour, they might be confounded with psoriasis or squamous eczema. 
But in every case the physiognomy of the disease in general may 
well be trusted for the establishment of a diagnosis, having in mind 
the color, the absence of intense pruritus and serous exudation, the 
disposition over the body as a whole, or in portions widely separated, 
and the rarely failing concomitant evidence of syphilitic infection. 

Large Acuminate Papular Syphiloderm. — Lesions of the 
character just described occasionally develop to an unusual degree, 
attaining the size of a coffee-bean in localities where the apex of 
each is free to push forward without coming into contact with adja- 
cent planes of the integument. Thus about the dorsum of the body, 
the gluteal regions, the calves of the legs, and the extensor surfaces 
of the forearms, they may be seen as fully developed, slightly scale- 
capped or scale-encircled, and grouped papules, often commingled 
with pustules and superficial ulcers, the polymorphic patch having a 
figure of eight or S-shaped outline. These are apt to be distinguished 
in patients under treatment, the influence of which has interfered 
with the full evolution of the disease. 

The Small Flat Papular Syphiloderm. — The lesions recog- 
nized under this title differ from those just described in that they are 
not acuminate, but distinctly flattened at the apex, this flattening being 
at times so pronounced that the lesion resembles a small button or plaque. 
The contour is roundish or oval-shaped. They are frequently en- 
countered on the face, especially near the mucous outlets, over the ante- 
rior and posterior surfaces of the trunk, and on the flexor aspects of 
the extremities. The palms of the hands are often affected. In color 
they exhibit the variation usual in individuals of different complexions, 
and in the same individual according to the condition of the circula- 
tion. Thus, on the face, a scarcely distinguished pink will become a 
deep, lurid, reddish-brown from an attack of sneezing, a paroxysm of 
laughter or rage, and violent exercise. The seborrhoeic condition 
noted on the face in the acuminate lesions is also occasionally seen 
about the plaques. The same is true of the scaling described above. 
The eruption is much less copious, as a rule, than with the other 
forms of syphilitic papules, due doubtless to the fact of its frequent 
occurrence in those subjected to some treatment. It differs from the 
lesion about to be described with respect to its size, being rarely 
larger than the smaller buttons employed as "shirt studs;" while the 



510 DISEASES OF THE SKIN. 

largest papules of the same variety may attain the size of the largest 
overcoat button. The diagnosis is in general that already given. 

The Large Flat Papular Syphiloderm, — Here the resem- 
blance to a button is even more distinct, the lesions occurring with a 
well-defined, firm, raised border, and a shallow depression in the 
centre, though at times, especially in moist situations, the superficies 
of the plaques is a smooth, flat plane. They commonly begin as 
macular lesions and rapidly develop at the periphery, this develop- 
ment often corresponding to centric involution by which the shallow 
depression described above is reduced to the level of the adjacent skin 
and the lesion transformed to a ring. In shape they are circular 
and oval ; and, in size, vary from a finger-nail to the section of a 
pigeon's egg. They have the usual variation in color, and may scale 
at the edge, or over the flat top, or the depressed centre. In moist 
situations they frequently secrete a muco-purulent fluid which smears 
the papules and adjacent integument ; and in the vicinity of the anus 
or genitals exhales an offensive odor. It is especially in such situa- 
tions that they occasionally degenerate by fissure or circular ulcera- 
tion. Condylomata Lata are such lesions, flat and secreting papules 
of the region named, somewhat transformed by the influence of heat, 
moisture, and either friction or apposition of contiguous integu- 
mentary folds. 

The eruption may become generalized, or be limited to certain sites 
of preference, as the face, neck, flexor surfaces of the extremities, and 
the ano-geuital region. It is either an early, late, or intermediate 
symptom of syphilis, in my experience occurring most abundantly in 
young and delicate skins, where the disease has been ignored, and 
therefore untreated; and most scantily in the thicker integument of 
middle life, where prompt resort has been had to appropriate medi- 
cation. 

Syphilitic papules undergo a series of modifications, under the 
influence of various causes, which may be enumerated as follows : 

(a) There is considerable hyperplasia of the cutaneous elements 
(papillary layer of the corium, rete, and bloodvessels), by which the 
papule becomes largely raised from the surface, so as to resemble a 
papilloma or wart, or the lesions characteristic of framboesia. In this 
way, rarely, a portion, or the entire surface, of the body may be 
covered with light-red or violaceous red, non-ulcerative, vegetating 
growths. They secrete freely, and the discharge is liable to concrete 
into crusts, and to exhale an offensive odor. De Amicis 1 has 
described a marked instance of this lesion occurring upon the scalp, 
under the title of the " framboesioid condylomatous syphiloderm." 
A translation of his paper by myself appeared in the Archives of 
Dermatology for October, 1879, p. 39. 

(6) There is considerable hyperplasia of the elements, in conse- 
quence of which the lesion spreads laterally, while its elevation from 

1 Anual. Clin, de Osped. Incurab. 



SYPHILODERMA, 



511 



the surface is prevented by contact with apposed surfaces. Thus is 
formed the broad, flat, moist papule, known as the vegetating mucous- 
patch, condyloma, plaque muqueuse, etc. The lesions, when unal- 
tered and fully developed, are of a decidedly whitish color, from the 
puriform mucus which covers them and which, as with so many of 
the syphilodermata in moist situations, is liable to exhale an 
extremely offensive odor. When the secretion is removed, the lesions 
are seen to be pinkish, or light or dark red in color, and to be either 
firm or soft, scarcely raised, and indefinite in contour, or distinctly 
elevated and very well defined. They are chiefly found in moist 
situations, where regions of the skin are apposed, as about the peri- 
neum, groins, axillae, mammae, nates, anus, genitals, and inner faces 
of the thighs. They may coalesce so as to form palm-sized patches, 
and frequently are associated with hyperidrosis, seborrhoea oleosa, 
and the dried products of secretion from the mucous outlets adjacent, 

Fig. 64. 




Vegetating condylomata of the vulva. (After Jullien.) 



(c) In consequence of changes in the superficial layers of the epi- 
dermis, the papules may become covered with scales, either at the 
base or apex, more commonly the latter, forming thus the papulo- 
squamous syphiloderm. The scales are of a dirty grayish hue, often 
desiccated, generally attached, rarely freely exfoliating. They are- 
relatively few, occurring where the lesions are closely set together. 
The desquamation may be the most suggestive feature of the patch. 
Beneath them, show distinctly elevated brownish-red papules or 
merely slightly elevated, dull-red or purplish-red maculations. 
When the scales accumulate at the base of the papule, they tend to 
surround it with a circlet or collarette of exfoliated shreds of 
epidermis. 



512 DISEASES OF THE SKIN. 

In consequence of the thickness of the epidermis in the palms and 
soles, the papular or papulo-squamous syphiloderm of these regions 
is presented Cinder somewhat atypical forms. These are recognized 
a- the Palmar and Plantae Syphilides. The dense stratum 
corneum of the epidermis in these situations is not readily raised from 
its underlying tissue into papular forms. Its pathological manifesta- 
tions in this disease are rather displayed in thickenings, separations, 
stainings, and frayings. 

Fig. 65. 




w 



Palmar syphiloderni. (After Keyes.) 

Here, therefore, are seen dull-red maculations, covered throughout, 
or at the edge merely, by scales or epidermal shreds; minute, firm, 
corneous thickenings, few or many, often without color in consequence 
of the depth of the vessels beneath the opaque horny layer ; aud dis- 
tinctly elevated (not flattened) and circumscribed papules, of the usual 
livid-red color, coffee-bean to small-nut in size, often aggregated in 
patches having a tendency to assume the circinate outline. These 
are covered with dirty-whitish, tenacious, half-loosened, epidermic 
flakes, which are quite characteristic. In yet other cases, usually in 
con-eqnence of the motions of the hand or foot or the exigencies of 
toil, irregularly angular losses of epidermis are visible, resembling 
the fracture of a pane of glass, which project, at the edges only, over 
deep fissures, broad ex ulcerations, or a ham-red, tender, and newly 
formed epidermic stratum. 

The eruption is frequently seen in the centre of both palms and 
soles symmetrically, rarely upon the dorsum of the hands and feet, 
aud then never typical, but always by extension from the former 
regions; also on the lateral surfaces of the hands, feet, fingers, and 
toes. It is a persistent, rebellious, and usually late cutaneous symp- 
tom of syphilis, occurring often six, eight, and more years after infec- 
tion. Rarely it is seen within a few months after the existence of 
chancre, and is then usually manifested in its simpler forms. 

The papulo-squamous syphiloderm bears in many instances a 
strong resemblance to the patches of psoriasis, but can usually be 



SYPHILODERMA. 513 

readily distinguished from the latter by a consideration of the 
following points : 

The syphilide is, as a rule, not generally diffused ; displays sym- 
metry only when it involves the palms and soles ; is elevated at the 
border of the patch; and observes the contour of the segment of a 
circle. Psoriasis is more widely diffuse; generally symmetrical; not 
specially elevated at the border of the patches ;_ and the latter are 
rather more completely than partially circular in outline. In the 
former there is generally a history of infection, of other cutaneous or 
mucous symptoms of the disease, and in the married woman, of 
abortions, miscarriages, or birth of diseased children. All this is 
wanting in psoriasis. In the latter there is a decided predisposition 
to the development of the disease about the extensor surfaces of the 
joints and the posterior aspect of the trunk ; the syphiloderm, though 
it may occupy these situations, can rarely be found thus displayed 
when the other surfaces are neglected. The scales in psoriasis are 
more lustrous ; more freely produced and shed ; aud exist signifi- 
cantly at an earlier period of the exanthem. It may be safely said, 
that with only such exceptions as prove the rule, psoriasis is never 
strictly limited to the regions of the palms and soles. A scaling, 
palmar or plantar disease of the skin in childhood is more apt to be 
psoriasic, though both diseases are seen in the early periods of 
puberty. 

Eczema is yet more readily recognized by its severe itching, its 
history of discharge and moisture, and its characteristic crusts. 
Ancient patches of squamous eczema are often very indeterminate in 
outline, do not ulcerate, and exhibit the scales on the surface of a 
much more deeply infiltrated area. Eczema of the palms and soles, 
when chronic, usually involves the dorsum of the hands and feet, 
whence it has extended to the former situations. When this is not 
the case, the eczematous infiltration if of long duration, will, in the 
vast majority of all cases, be found to involve uniformly and evenly 
the entire palm or sole, including the palmar or plantar faces of the 
digits. Eczema is, finally, much more frequently encountered either 
solely upon the right hand in right-handed patients, or to a greater 
extent in that organ by reason of its preference in the performance of 
function. This is less common in syphilis. 

Syphiloderma Vesiculosum. 

The vesicular are either the rarest of all cutaneous symptoms of 
syphilis, or do not actually exist. Certain French authors describe 
pin-head to pea-sized, conical, globoid or umbilicated, isolated or 
grouped, and crusting elevations of the epidermis, with lucid or 
cloudy contents, seated upon the face and genitalia. The eruption is 
described as an early syphiloderm, often exhibiting a halo of charac- 
teristic tint, the resulting crusts being granular and somewhat lighter 

33 



514 DISEASES OF THE SKIN. 

in color than those which are commonly seen in the disease. Both 
small and large vesicles have been thus assigned to the disease. 

But the larger number of such lesions are, without question, 
either immature pustules, eczematous lesions in syphilitic subjects, or 
pure accidents of the syphilitic process. With regard to the first, it 
may be said that the pustular syphiloderm not rarely begins as a 
vesicular lesion ; with regard to the second, that coincidences of so 
common a disease as syphilis with other cutaneous disorders is a 
matter of frequent observation ; and with regard to the third, 
bearing in mind the large quantity of iodide of potassium swallowed 
for the relief of the disease, and its capability of exciting a vesicular 
eruption, it can be reasonably concluded that some, at least, of the 
cases of so-called vesicular syphilis have been imperfectly studied. 

Syphiloderma Pustulosum. 

Pustular lesions in syphilis present a wide range of differences. 
They vary in size from a pin-head to a finger uail ; may be acu- 
minate, flat, hemispherical, or irregular in shape; may be few or 
very numerous ; distinctly localized or generally dispersed ; grouped 
or disseminated, and may occur from the first as minute vesico- 
pustules, or as pustular transformations of variously sized papules. 
They may be surrounded by inflammatory areolae, or spring from an 
unaltered integument, or be sub-epidermic in situation, and scarcely 
project from the surface. They may be seated upon superficial or 
deep, sharply cut, secretory ulcers, and are usually followed by 
crusts differing in bulk and consistency, forming thus the pustulo- 
crustaceous syphilide. According to the depth of the ulceration at 
the base are they followed by cicatrices. Pigmentation is a fre- 
quent result. The crusts which form by the desiccation of their 
contents are usually reddish-brown to greenish-black in hue, occur 
in strata or laminae by accretions from beneath, and, even when 
superimposed upon a moist and secreting ulcer, are quite adherent at 
the edges. They may occur early or late in the disease, and at either 
epoch constitute trifling or grave cutaneous lesions. They have a 
marked predisposition for involvement of the sebaceous and pilary 
follicles, and are frequently disposed about the mucous outlets of the 
body. 

Small Acuminate Pustular Syphiloderm. — This exanthem 
is usually largely diffused over an extensive surface, and probably 
represents, as Jullien has suggested, a transformation from papular 
lesions due to either a pyogenic tendency of the infected subject, or 
to uucleanliness and external irritation of the skin. It is certainly 
rare in patients of the better class who are seen in the private 
clientele of the physician. The pustules are generally recognized 
about the pilo-sebaceous orifices, and upon minute papular lesions, 
which, as undisguised elements of the eruption, may be interspersed 



SYPHILODERMA. 515 

among the latter. They are acuminate and contain but a droplet of 
cloudy serum or pus, whose desiccation furnishes a thin yellowish or 
reddish-brown crust. The fall of the latter exposes the grayish 
epidermal fringe of the base occasionally seen in papules of similar 
size. 

The lesions may be discrete, confluent, disseminated, or in groups 
affecting the curve of a circle. The extremities and trunk are chiefly 
involved, though the disease may be well nigh universal. Under 
the influence of treatment, minute, punctiform, and pigmented cica- 
tricial atrophic depressions form, which are not persistent. The 
eruption may be an early or late secondary symptom, but is usually 
first seen within a few months after infection. Relapses occur when 
treatment has been irregularly pursued. Their concomitants are 
those symptoms of syphilis proper to the period in which they 
appear. 

Large Acuminate Pustular Syphiloderm. — The lesions are 
here usually coffee-bean sized pustules, which may spring from 
macular or smaller pustular lesions, very rarely from an indurated 
or papular base. They have a thin roof-wall, occurring by prefer- 
ence where the epidermis is delicate, and are often surrounded by a 
halo. They are usually acuminate, but may, after full evolution, 
slightly flatten at the apex in consequence of partial collapse. The 
crusts are bulkier and darker in color than those of the lesions just 
described ; their bases are superficially ulcerated. They occur slowly 
or with rapidity, in disseminated or grouped forms, usually at an 
early period of the disease, though commonly after the appearance 
of some syphilide of another type. 

Small Flat Pustular Syphiloderm. — This is a relatively 
frequent manifestation of syphilis, occurring upon the face, scalp, 
trunk, and the flexor surfaces of the extremities. It exhibits a 
decided tendency to characteristic and circular grouping about the 
mucous outlets of the body. Such groups are composed of small, 
flat pustules, originating as reddish, macular lesions which tend to 
dry in flattish, irregular, adherent crusts ; and the latter either sur- 
pass the limits of the diseased surface beneath, or are conspicuous 
upon a dull brownish-red area of inflamed, and even at times 
ulcerated, aspect. Often the pustules are so closely set as to become 
confluent, and in such case a single convex crust, like a carapace, 
will often completely cover the involved area. Frequent sites of the 
exanthem are the regions about the nose and the lips, as also the 
chin, beard, and the anterior faces of the elbow and wrist-joints. 

The eruption is of the pustulo-crustaceous type, and may be 
evolved from either papular or macular lesions. In this country, it 
is rarely long untreated, and when in full evolution is, therefore, not 
often presented for observation. It is usually amenable to judicious 
treatment, and, when followed by severe ulceration, destroying one 
ala of the nose or a part of the lip, the patient has usually suffered 



516 DISEASES OF THE SKIX. 

from either cachexia or neglect. In these same cases, less severe 
phenomena are presented in the superficial serpiginous syphilitic, the 
lesions extending in circinate or annular gyrations about a sound or 
previously involved and healed centre. Thus a circlet of crusts, 
with underspreading superficial ulceration, perhaps alternating with 
pustules of various ages and reniform cicatrices, will surround the 
elbow or traverse the scalp. The resemblance to pustular eczema 
is at times suggestive; but the ulceration and outline will aid in 
their discrimination. The lesions are usually late among the earlier 
symptoms of the disease, but may be delayed for six months after 
infection. They indicate, as a rule, either severity of the disease, or, 
much more commonly, constitutional impairment. 

Large Plat Pustular Syphiloderm. — The lesions here are, 
naturally, fully developed forms of those described above. Like the 
latter, they originate as usually numerous, maculo-papular symptoms, 
which gradually deepen into pea-sized and even larger flat pustules, 
whose further history is one of enlarging, blood- mixed, reddish- and 
greenish-brown, also flatfish crusts with underspreading pus-bathed 
ulceration of varying extent. The superficial variety of this syphilo- 
derm is distinguished from the deep, chiefly by the extent of its 
ulcer, the size of its superimposed crust, and the slighter, dull-red 
areola which encircles it. 

The deep variety, like the superficial, may be limited to the scalp, 
face, neck, and flexor aspects of the extremities, or it may be much 
more widely diffused. I have seen the entire surface of the body 
covered with discrete lesions of this type in cases of unusual neglect 
or profound cachexia. It is usually of late occurrence, but in the 
so-called "galloping syphilis" of the French, it may be precocious in 
development. The lesions are at the onset nodules or tubercles, 
which become transformed into pus, and which have a deep infil- 
trated base with a dark brown halo. Incrustation follows, with the 
formation of a conical, roundish, or oval-shaped, blackish-brown crust, 
beneath which lies a clean-cut ulcer, its sharp edges usually exactly 
roofed by the incrustation. The crust thickens by concretions from 
the foul and purulent ulcer beneath, and spreads at the periphery 
while it thickens in the centre. In this way, the stratified crust 
comes to resemble an oyster-shell, the condition described by some 
authors as Rupia, a term once employed as the name of a disease. 
The ulcer which is exposed after removal of the crust is of charac- 
teristic syphilitic type, in its deep base, foul floor, clean-cut edges, and 
sanguineo-purulent secretion, attaining at times a diameter of several 
inches, and having a circular, reniform, or horseshoe-shaped contour. 
The degree of destruction it may occasion is proportioned to the 
constitutional vigor of the subject and the treatment pursued. It is 
usually a grave but may be a malignant exanthem, though under 
favorable circumstances it is easily managed. It may be an early, 
though is usually a late symptom of the disease. The pigmeuted 
scars left are characteristic aud indelible. 



SYPHILODERMA. 517 

Syphiloderma Bullosum. 

Bullae in acquired syphilis are late and relatively rare lesious. 
They are pea- to large nut-sized elevations of the epidermis, filled at 
first with a cloudy serum, which is soon transformed into pus, and 
often mingled with blood. They have usually a characteristic halo 
about the periphery; are roundish or oval in contour; are usually 
discrete, rarely disseminated, and, after development, produce char- 
acteristic crusts with underlying ulcers, identical in features with 
the rupioid sequelae of large syphilitic pustules. The eruption is 
localized by preference upon the extremities, more particularly the 
lower extremities, and is indolent in its course. It is always signifi- 
cant of a cachectic condition in the subject of the disease. Its more 
frequent occurrence in congenital syphilis will be described later. It 
is to be distinguished from pemphigus vulgaris by its characteristic 
crusts and ulcers, considered in connection with the history and 
associated symptoms of lues. 

Syphiloderma Tuberculosum. 

In this eruption, the lesions are usually multiple, flat, roundish, 
circumscribed, firm, light to dull crimson-red nodules, beginning 
commonly as maculae of a lurid hue. They vary in size from a 
coffee-bean to small nut and involve the entire thickness of the skin, 
often also of the subcutaneous tissue. Their surface is smooth, 
glazed, or desquamating ; and their evolution peculiar in this, that 
they rarely exhibit apicial pustulation or ulcerative degeneration. 

The eruption is, with few exceptions, usually limited to one or 
more regions of the body, such as the forehead, the chin, the nucha, 
the buttocks, and the outer surface of the thighs. It is less often 
disseminated thau grouped. Occasionally but a single tubercular 
lesion may be displayed upon the surface of the body, the recognition 
of whose character usually demands some skill on the part of the 
diagnostician. When occurring in groups, the typical circinate 
appearance of the syphilodermata in general may be wanting, the 
patches having an irregular boundary ; but at times the circular, 
reniform, or horseshoe-shaped outline is quite distinct, with an 
inclosed area of integument, unaltered or the seat of atrophic changes. 
At other times the lesions assume a serpiginous character and distri- 
bution, a condition to which the term 



Syphiloderma Tuberculosum Serpiginosum 

has been applied. Bumstead and Taylor, however (wisely it seems 
to me), prefer to reserve that title for the description of the serpigi- 
nous syphiloderm of ulcerative type. 

In exceptional cases, the lesions thus described are marked by 
secondary changes. They may become covered on the surface with 



518 



DISEASES OF THE SKIN 



a thin yellowish crust; may lose their firmness and become soft 
and rather more lurid-red in hue from colloid, or even rarely 
suppurative, degeneration ; may vegetate luxuriantly and become 
the seat, especially on the scalp, of warty growths, smeared with a 
semi-purulent secretion of disgusting odor (syphilis papillomatosa, 
syphiloderma frambocsioides) ; or may finally ulcerate, the super- 
imposed crust thickening in bulk, deepening into blackish and 
greenish shades, and covering typical syphilitic exulcerations, with 
characteristic edges, floor, base, and secretion. The degeneration in 
the latter case may be rapid, and the destruction extensive. This is, 
however, of rare occurrence. 

Fig. 66. 




Ulcerative tubercular syphi 



The course of the eruption is indolent, months usually elapsing 
before its full evolution is accomplished. In untreated cases there is 
unquestionably produced a generalized and symmetrical syphiloderm. 
It is rare, however, even in hospital and dispensary cases, to observe 
such generalized development; the more superficial, generalized, and 
symmetrical the lesions, the briefer, as a rule, is the interval between 
such an eruption and the date of infection. The later the lesions, 
the more apt are they to be asymmetrical, localized, and profound in 
their involvement of the deep tissues. This syphiloderm rarely 
appears in the second, more often in the third or fourth, still more 
rarely in the fifth, tenth, or fifteenth year of the disease. 

Resolution occurs by resorption leaving in the site of the tubercles, 
according to their age, size, and contents, livid and pigmented macu- 
lations, or peculiar, pigmented, atrophic, cicatriform areas. Scars 
following the ulcerative lesions are typical in color, shape, and career, 



SYPHILODERMA. 519 

the pigmentation of both cicatrix and areola blanching from centre to 
periphery, and leaving a delicate, dull-whitish, glazed, or slightly 
desquamating membranous new growth, ancient relics of this process 
resembling in appearance thin, small coin- and larger-sized, circular 
sheets of mica. 

The diagnosis is between lupus vulgaris, lepra, epithelioma, and 
psoriasis. In lupus, the age of the subject, the character of any scars 
left upon the surface, the chronicity of the disease, and the absence 
of a history of polymorphism, will usually point to the nature of the 
disease. The tubercles of lepra are very much more indolent than 
those of syphilis, and have a characteristic oiled or varnished look, 
never the livid or dull crimson color of those last named. Set upon 
the forehead, the tubercles of syphilis, nearer the line of the hairs, 
never give the leonine aspect of those at the lower border of the fore- 
head and over the eyebrows of the leper. In epithelioma, the age of 
the subject and the history of the disease are always significant. In 
the early stage of epithelioma, the patient is often in a condition of 
excellent general health, while the imprint of cachexia is distinct in 
tubercular syphilis of the skin. In the later stages of epithelioma, 
the ulcer with everted edges and eroded, hemorrhagic floor, " var- 
nished" by its translucent secretion, is totally different from the 
"punched out," syphilitic ulcer with its puriform secretion and dis- 
colored crusts. The deep infiltration of even the desquamating 
tubercular syphiloderm will distinguish it from the circular patches 
of psoriasis. 

Syphiloderma Gummatosum. 

The gumma is a lesion peculiar to syphilis; no other disease ex- 
hibiting an exactly similar feature. It is usually a late or so-called 
tertiary manifestation of the disease ; and is commonly observed in 
the form of one or relatively few, subcutaneous, strictly circumscribed, 
firm, well rounded, painless and indolent tumors or nodules which, 
when first observed, are scarcely larger than a pea. They are then 
covered by an unaltered integument and are quite movable. 

Very slowly they may, when untreated, increase in size till they 
have the dimensions of a marble, an egg, or even bodies of a consid- 
erably larger size. Sooner or later, when not resolved by treatment, 
they usually become attached and the overlying skin becomes involved, 
showing by its livid, .reddish, or purplish hue, and its hypersemic 
areola, that it threatens to yield. Finally, at one or several points, the 
skin is so thinned as to be incapable of further resistance, and a thick 
sanious secretion is exuded, whose gummy character has given the 
lesion its name. When the inflammation has been active, its secre- 
tion may be wholly or partly purulent, and in that case be fur- 
nished, either by the contents of the tumor, or the peripheral tissue 
which participates in the process. Ulcers always result, occasionally 
fistulous in type, roundish or oval in contour ; with edges clean cut, 
and floor purulent and extending to the subcutaneous tissue, tendons, 



520 



DISEASES OF THE SKIN. 



Fig. 67. 



aponeuroses, curtilage, or bone. Thin and yielding hands or bridges 
of undermined skin often extend between several such solution- of 
continuity, and usually melt down in the presence of the destructive 

process. When repair is progressing, which is decidedly the rule as 
regards the ultimate result, granulations spring from the floor, the 

edges contract, and the gummatous 
eventually exhibits the appear- 
ance of a simple ulcer, save in 
the thinned, purplish, pigmented 
appearance of the outlying in- 
tegument. The scars are typical, 
bleaching from the centre, and 
may be attached to periosteum or 
bone, though this is exceedingly 
rare. Considering the depth of 
the process, the gumma of the 
skin is certainly as a rule suc- 
ceeded by less evidence of de- 
struction than is threatened at 
the height of the process. About 
the neck', the cicatrices may be 
linear in shape and slightly puck- 
ered. Upon the lower extremities 
and trunk, they are usually cir- 
cular or oval. 

But one gumma may appear 
upon the person of a single indi- 
vidual and, when this is the case, 
it will usually be found upon the 
leg. Half a dozen or more may 
at other times coexist. In one 
instance, I counted more than one 
hundred upon the person of a male patient who was the father of 
two syphilitic children, and who at the time had also symptoms of 
visceral syphilis. This number is greatly in excess of any previously 
observed by me in a single case. Gummata may develop upon any 
part of the body, and when situated over the trunk of a nerve 
become the seat of severe neuralgic pain. They are particularly 
amenable to treatment ; and may undergo resorption, leaving little 
or no trace of their former existence. 

Gummata are to be distinguished from fibrous, carcinomatous, and 
lipomatous tumors, as also from indurated and enlarged lymphatic 
ganglia. As they occur in very marked preponderance below the 
level of the knees, and are for the most part single or relatively few 
in such situation, they can by their position alone be frequently 
differentiated from each of the new growths mentioned, no one of 
which occurs by preference upon the lower extremities. As they are, 
moreover, relatively late lesions of syphilis, a history of preexisting 
symptoms of that disease can usually be obtained. 




Syphilitic gummata of head and face. 
(After JlLLIEN.) 



SYPHILODERMA. 521 



Erythanthema Syphiliticum. 

Under this title, Dr. E. B. Bronson, of New York, 1 describes a 
condition observed by himself in syphilitic patients. Upon a well 
defined, crimson or livid, erythematous surface (face, palms, soles) 
appeared an abundant crop of pea-sized vesico-pustules, which were 
converted later into an exuding, whitish, elevated, and diphtheroid 
patch. The multiformity of the exanthem was characteristic. In 
parts it suggested the hydroa bulleux of Baziu ; elsewhere, the derma- 
titis herpetiformis of Duhring. The fluid exudation that affected the 
face was not characteristic of the evolution of the palmar and plantar 
lesions. 

Later, warty, papilliform lesioDS appeared over the face and neck, 
somewhat resembling secreting condylomata, and surmounting, for 
the most part, a dusky-red or erythematous surface. 

The author regarded the exanthem as primarily a syphilitic 
product, but not pathologically or etiologically a true syphiloderm. 
Its origin was possibly similar to that of the angioneurotic, tropho- 
neurotic, or reflex phenomena of skin disorders in general. 

Syphiloderma Infantile, Acquisitum et Haereditarium. 

Syphilis may be acquired by the infant and child at any period 
after birth, as, for example, by immediate contagion from the nipple 
of the nurse, or mediately, as by the use of utensils smeared with a 
secretion capable of transmitting the disease. Such acquired infantile 
disease displays for the most part the symptoms observed in adult 
years, except that the delicate and tender skin at this early period of 
life is apt to exhibit the moist and secreting lesions of syphilis. The 
mucous patch, the pustule, and the condyloma, are here more common 
than the papulo-squamous symptoms of the adult. Some influence 
is also exerted upon the disease by the dress, habits of life, and mode 
of obtaining nutriment, which are conditioned upon the helplessness 
of the young child. In this way the soiled napkin over the ano- 
genital region, the warm covering of, and free diaphoresis from, the 
general surface of the skin, and the frequent contacts of the lips with 
the nipple, suffice to determine in special regions, particular local 
expressions of the constitutional vice. It is much less grave in char- 
acter and portent than the inherited form of the disease. 

Hereditary syphilis may be first displayed in infancy or early adult 
years, and is always strictly transmitted by inheritance from one or 
both parents. The consideration of the disease being in these pages 
limited to its cutaneous manifestations, it is first to be noted that the 
infected foetus may be prematurely expelled with cutaneous symptoms 
displayed upon its surface. This generally argues in favor, either of 
intense syphilis in one or both progenitors, or, more commonly, of 
relatively recent infection of the latter. Under these circumstances, 

i Medical Eecord, September 4, 1S8fi, p. 253. 



522 DISEASES OF THE SKIX. 

there are usually evidences of the death of the foetus at some date 
prior to its expulsion, the skin being macerated and the epidermis 
raised from tin' corium in few or many bullous lesions, beneath which 
the derma exhibits a livid reddish or purplish hue. 

When the infant is born with a clean skin, it may be shrivelled 
and emaciated, or fat and presenting the appearance of sound health. 
Soon after, however, cutaneous manifestations appear, usually not 
before the conclusion of the first mouth, more commonly during the 
second, very rarely after the third and fourth. The earlier the date 
of such explosion, the more intense as a rule is the evidence of the 
disorder. The first symptoms displayed are significant of visceral 
involvement, and are, in brief, those of marasmus. Emaciation pro- 
gresses rapidly ; the skin seems stretched unnaturally over the facial 
boues ; the expression is that of physical distress ; the cry becomes a 
fretful moan ; the integument loses entirely the rosy hue of the 
healthy infant, and acquires instead a sallow or muddy tint ; and 
very peculiar wrinkles or puckered lines radiate from the angles of 
the lips. Few observers have failed to notice the resemblance which 
then exists between the faces of these emaciated little creatures and 
those of the aged of both sexes. 

In all this, however, there is absolutely nothing characteristic of 
syphilis, as distinguished from other wasting diseases of infancy. 
Chronic tubercular meningitis and the gastro-intestinal disorders of 
infancy in their extreme expression furnish a precisely similar picture. 
This is natural enough, since all depend alike upon a similar cause, 
failure of proper performance of function on the part of the viscera 
in consequence of pathological alterations. 

The coryza of the syphilitic infaut is, however, soon declared, and 
speedily gives a clew to the nature of the morbid process. The 
discharge from the nares, at first serous, later purulent, desiccates 
sufficiently to obstruct the nasal passages, or, in consequence of the 
tumid condition of the membrane lining the latter, is prevented 
from escaping. Often it is furnished by mucous patches forming on 
the Schneiderian membrane. At times, crusts form so as to accumu- 
late externally about the nasal orifices, and then are seen to be 
similar to those which are apt to form also at the angles of the mouth. 
In this way the characteristic "snuffles" of the syphilitic infant is 
induced, in consequence of which it is obliged when nursing to release 
the nipple from its mouth, in order to respire, an act often accom- 
panied by a hoarse cry. The breathing of such an infant, even when 
asleep, or awake and undisturbed, is always sufficient to arouse a 
suspicion as to the nature of the disease from which it is suffering. 
The mouth, larynx, vulva, and anus are often the seat of similar 
lesions, whose development into an obstructive tumefaction secreting 
more or less profusely, or into moist condylomata, will depend largely 
upon the seat and surroundings of the lesion. 

The cutaueous symptoms of the disorder, presented usually at or 
about this time, are macular, papular, pustular, bullous, or furuncular, 
two or more of them being at times commingled, attesting thus the 



SYPHILODERM A. 523 

identity of the disease with the polymorphic acquired forms of 
maturer years. Maculae are early to appear upon the trunk, face, 
and extremities, usually of a livid reddish hue, commingled with 
papules, and indeed often occurring as the first manifestation of the 
latter. They are irregular as to shape, and though occasionally 
pinkish, discrete, circinate, and coffee-bean sized, often constitute a 
diffuse, coppery-red, or violaceous, glazed, or moist and secreting 
surface, affecting an entire region, as the neck, the trunk, or thighs 
and genitalia. Deep excoriations and even fissures occasionally form 
in these extensive patches, and the secretions may incrust them irregu- 
larly, the general aspect of the patch somewhat suggesting an ecze- 
matous condition, yet remarkably differing from the latter in color. 

In hereditary as in acquired syphilis, the type of all the eruptive 
symptoms is to be sought in the papules which may spring from the 
maculae described above, and develop into pustules, bullae, or condylo- 
mata; and, in the former case, dull red or violaceous papules of 
lenticular size, occur either in asymmetrical or symmetrical arrange- 
ment, discrete or agglomerated in patches of infiltration. They may, 
upon the buttocks especially, scale at the apex ; or, particularly, upon 
the palms and soles, constitute, by fusion a thickened desquamating 
epidermal patch ; or, commonly about the ano-genital region, the 
interdigital spaces, the axillae and face, become moist, and secrete a 
puriform mucus. By vegetation or hypertrophy, they develop into 
flat or fissured condylomata, smeared with an offensive, yellowish, or 
yellowish-white discharge, and vary in size from a coin to a lesion an 
inch or more in diameter, with corresponding variation in the degree 
of their elevation from the surface. The latter may be few or very 
numerous. Sometimes a child will appear to be well nigh covered with 
large, moist, secreting papules. The author has seen an infant with 
snuffles and maculae of the trunk, having but a single condyloma of 
the anal region. Again, the papulo-condyloma may ulcerate deeply 
and crust. It should be remembered, in studying these symptoms 
from a verbal description, that they are those of a cachectic infant 
affected with a grave disease. Death often interrupts the sequence of 
the manifestations here described. This event is usually preceded by 
the signs of apparent amelioration, shrinkage of hypertrophic growths, 
and decolorization of hyperaemic lesions and patches. Of the other 
outaneous symptoms of hereditary syphilis, vesicles are the rarest, the 
smaller being occasionally seen, having a conical apex, with serous 
contents, closely set together about the lips, and springing from a 
violaceous infiltrated patch. The resulting crusts never have the 
reddish-yellow tint of those observed in eczema, nor, after rupture, 
are they followed by serous oozing from a wounded epidermis. The 
larger lesions of this sort are usually transformations of papules 
which rapidly assume a pustular phase. 

Pustular eruptions, in this form of syphilis, may be discrete or 
confluent, localized or generalized. They are particularly apt to 
occur in groups about the mucous outlets, with maculo-papular 
lesions developed elsewhere, and may result in ulceration, often after 



524 DISEASES OF THE SKIN. 

development into bullae with pustular or sanious contents. The 
resulting crusts are bulky and dark colored, and, especially upon the 
face, disfiguring. The subjective sensations are probably insignifi- 
cant, since the child does not attempt to tear the surface, as in pustular 
eczema. The cachectic condition of the little patient, when these 
lesions are large and numerous, is usually pronounced. They may 
be seen in typical development by the side of the nail, occasionally 
involving the matrix, and productive, in this situation, of con- 
siderable swelling of the digit, with an ulcerative sequel, which com- 
monly results in distortion, and ultimate loss, of the nail-substance. 
Onychia, however, may result from perverted nutrition of the part, 
with increase in its friability, loss of lustre, assumption of a dirty 
grayish hue, and phalangeal oedema. These changes are analogous 
to those resulting in loss of the hair where the follicles have been 
imperfectly nourished. 

The furuncles which form in other cases are exaggerated manifes- 
tations of the same pyogenic tendency in the skin of the infant, a 
complication common to syphilitic and other cachectic conditions in 
young children. They may be few or numerous, and are chiefly 
characterized by their indolence, the absence of laudable pus in their 
conteuts, the ulcerative condition left after their evacuation, and the 
bluish or purplish condition of the integument which surrounds 
their edges. 

Bulla? in hereditary syphilis are early or late manifestations of the 
disease, and may be represented by a single lesion on the palm or 
soles (the site of their predilection), or constitute a symmetrical 
generalized efflorescence. They should be regarded as evidences of 
a grave form of the disease, being often the precursors of a fatal 
issue, as indicating a feeble resistance on the part of the epidermis to 
the fluid exudate furnished from the corium beneath. In severe 
cases, the bulla? are ill developed, and the integument will be seen 
to be marked here and there by small coin-sized and larger disks or 
plaques of macerated epidermis, separated from the derma by a thin 
film of serous, sanious, or purulent fluid, in quantity insufficient to 
raise the roof above the general level of the integument. When fully 
developed, there may be conical, rounded, flat, or quite flaccid, and sur- 
rounded by an infiltrated border of dark reddish or violaceous hue. 
Their color varies with the color of their contents. Their subsequent 
career is concluded by shallow or deep ulceration, the base secreting 
a sanious discharge. Crusts may form if the patient survive. A 
fatal termination of the disease is usually announced by their flat- 
tening or collapse. They may be commingled with pustules and 
maculo-pa pules, condylomata, mucous patches of the anus, mouth, 
and nares, but are somewhat different from the other lesions described 
in this, that they may constitute a uniform efflorescence, no other 
cutaneous symptoms being manifested. This is explained by the fact 
to which attention has been directed, that they represent the state of 
feeblest resistance in the epidermis, the fluid exudate of exceedingly 
low grade mechanically separating the rete from the tissues beneath. 



SYPHILODERMA. 525 

Tubercles and subcutaneous gummata may develop in hereditary 
syphilis, but are usually late manifestations of the disease, one or 
more years elapsing before their appearance. Their behavior is 
scarcely different from that of those observed in the acquired forms, 
although the destruction wrought by their degeneration in very late 
manifestations may be of the most intractable type. Usually there 
is a preceding history of parental or inherited disease, and coincident 
symptoms or sequelse of such, in the altered teeth, described by 
Hutchinson, of London, in an ancient keratitis, or iu a hopeless form 
of surdity. 

Mucous patches are very constant symptoms of the disease, and 
represent papules of the mucous membrane, which differ from those 
seen in the skin only because they are moistened, macerated, and 
flattened by juxtaposition of neighboring tissues. They are sur- 
rounded usually by a lurid halo, and may have the pearly whiteness 
always seen when the epidermis of mucous membranes is detached 
wholly or partly from the corium ; or may lose this protecting disk 
in shreds or patches, and show, beneath, an engorged, or ulcerated 
and secreting tissue. They may be isolated or broadly confluent; 
and oval, circular, or decidedly linear in shape; the last named 
appearance being characteristic of those existing at the angles of the 
mouth. 

They are to be recognized as distinct from both the parasitic and 
non-parasitic forms of simple stomatitis or thrush, the former being 
due to the presence of the o'idium albicans. In both of the non- 
syphilitic disorders, the mouth of the child will be seen to be very 
generally, uniformly, and symmetrically involved, the circumscribed 
patches being distinctly discrete and resembling in color, soft whitish 
or yellowish flocculi of curdled milk. The diagnosis is always 
greatly aided by noticing the well-nigh constant occurrence of patches 
just at the angles of the syphilitic mouth, which latter has also the 
seamed and puckered appearauce described above. Snuffles, syphilo- 
dermata, and marked cachexia, when established, will leave little 
doubt as to the nature of the malady. 

The future of the infant affected with hereditary syphilis is not 
always as dark as might be gathered from what has preceded. In 
this, as in the acquired form of the disease, benignancy may be a 
conspicuous feature of the entire process. The evolution of the 
disease may be tardy; its symptoms few and unimportant; its amena- 
bility to judicious treatment speedily demonstrated. Still, the fact 
remains, that the disease when inherited is far graver than when 
acquired, the victim entering the world with its viscera and bones 
liable to profound pathological alterations. 

Etiology. — Syphilis, in the course of which appear the syphilo- 
dermata, is produced invariably either by infection, accidental or 
intentional, or by the obscure influences of heredity. The methods 
of transmission may be immediate as in sexual congress, kissing, and 
nursing at the nipple, by which act the child may infect the nurse 



526 DISEASES OF THE SKIN. 

with the secretion of the mucous patches in its mouth, or may, instead, 
receive the disease from the excoriations on the breast of the lattre. 
Or the disorder may result from the medium of utensils charged 
with an infectious secretion, such as the needles of the tattooer wet 
with saliva commingled with diseased mucus, or the lancet of the 
vaccinator covered with an intoxicated blood. Generally it may be 
said that all the discharging and moist syphilodermata are sources of 
danger to a sound individual, both in the acquired and inherited 
forms of the disease. By these and other similar methods, persons 
of both sexes, and of all ages, may become infected. 

However begotten, the syphilodermata are yet not excluded from 
subjection to the long list of external irritants which may in turn 
annoy the skin. The influence of a hot bath, or the excitement and 
perspiration of the dance, will often invite to the surface a macular 
syphilide which might otherwise be less fully developed; and fric- 
tion, as by the hat-baud over the forehead, the cuff at the wrist, and 
the shoe over the foot, demonstrates its influence by daily examples 
of determination of the morbid process to special localities. The same 
may be said of filth, such as the feces on the napkin of the infant which 
frequently provoke in this region the vegetation of condylomata. It 
is a mistake to suppose that syphilis, and syphilis only, is responsible 
for the exanthemata of that disease in all shades, grades, and situa- 
tions. Soap and water are as efficient in preserving the skin of the 
syphilitic as of the sound ; and the infected tobacco-chewer pays a 
price for his nauseous habit. Poverty, misery, and wilful neglect or 
ignorance of the laws of hygiene, are responsible for a long and 
lengthening list of the complications of the disease. 

Pathology. — The pathological anatomy of syphilis and the syphilo- 
dermata has been carefully studied by a large number of observers, 
including Virchow, Wagner, Cornil and Ranvier, Neumann, Auspitz, 
and Biesiadecki. It must be admitted that the result, even though 
it present a fair picture of the pathological appearances exhibited by 
the several lesions subjected to examination, is yet far from furnishing 
an explanation of the nature and peculiarly capricious career of the 
disease. Without stopping to consider, much less discuss, the 
numerous conflicting theories respecting the nature of syphilis, 
which the investigations of the eminent authors named have not yet 
succeeded in either disproving or establishing, it can be merely 
asserted to-day that the solution of this important question has not 
yet been reached. Under the microscope, it can be clearly deter- 
mined merely, that the recognized processes of hyperemia, exudation, 
hypertrophy, new growth, and degeneration (caseous, fatty, amyloid, 
atrophic, and necrotic) occur in syphilis as in some other disorders 
with cutaneous lesions ; that the specific character of the disease is 
not betrayed by any specificity of elements or of their arrangement ; 
and yet that every pathological process of syphilis bears the imprint 
of the malady whose influence it acknowledges. Here is a lesson 
certainly confirmed by clinical facts. With the possible exception of 



SYPHILODERMA. 527 

the gumma,' there are no cutaneous lesions of syphilis which are 
peculiar to itself, and yet there are certain modes of behavior by 
which each, when carefully studied, betrays its identity. It is then 
by the modality rather than by any essential character of the syphi- 
litic process, that it is to be differentiated from all others. 

The papule, the tubercle, and the gumma may be regarded as 
typical pathological developments of the disease, as they certainly 
constitute the basis of its common and important cutaneous manifes- 
tations. One of them indeed, the gumma, may develop in any organ 
of the body other than the skin. Under the microscope, these lesions 
are seen to be made up of a new growth whose numerous, small, 
rounded, or spindle-shaped elements, whether derived from connective 
tissue or outwandered leucocytes or both, and whether found, as they 
may be, in the rete, the corium, or the subcutaneous tissue, very 
probably represent transformation of protoplasm previously existing, 
or resulting from embryonal metamorphosis of such preexisting 
elements. Kaposi well summarizes the chief peculiarities of this 
new growth, by remarking: First, that its elements are distinctly 
circumscribed and homogeneous, differing, the minutest papule from 
the largest tubercle, only in respect to volume ; second, that they are 
inapt for permanent organization, but retrograde and disappear either 
by resorption or by suppuration ; third, that they are remarkable for 
their tendency to coincident evolution and involution, usually in a 
centrifugal direction, the younger peripheral portions presenting the 
characters of recent infiltration, while the more ancient situated at 
the pathological centre, are earliest to disappear. 

This new growth naturally plays a more important part in some 
lesions than in others. Scarcely discernible in the hyperemia of the 
macular lesions, and well defined in the papule and its modifications 
(the tubercle, the condyloma, and the forming gumma), it is repre- 
sented in the vesicle, pustule, bulla, and degenerating gumma by 
either a fluid exudate composed of granular, cloudy, and nucleated 
elements, or by a soft, succulent, grayish, or grayish-red homogeneous 
mass, yielding a scanty juice, and not yet completely transformed by 
degeneration to the fluid condition. Beneath and about any of these 
last-named lesions, the circumscribed new growth may lay a founda- 
tion or erect a wall, which unmistakably asserts the unity of all such 
processes. 

Viewed comprehensively, the multiform developments of the 
syphilitic new growth are seen to be incontestably more rapid of 
evolution and involution than, in their average career, are all the 
neoplasmata. Sarcoma alone competes with it in this regard. Lepra, 
lupus erythematosus, lupus vulgaris, keloid, xanthoma, and the large 
majority of all forms of epithelioma outlive, as a rule, generations of 
syphilodermata. This relative rapidity of career has entailed upon 
the disease its possibilities in the direction both of benignancy and 
malignancy. Whether, as it may, it destroy life, or, as may also be 
the case, it so slightly interfere with health as well nigh to pass 



528 DISEASES OF THE SKIX. 

unnoticed, in either event the total period of its activity is relatively 
brief. 

The demonstration of the bacillary origin of syphilis, as already 
stated is not yet complete. Every fact in its history, however, and 
the recent advances in the discovery of the part played by micro- 
organisms in the production of other diseases, point unmistakably to 
a parasitic origin of syphilis. There is reasonable ground for believ- 
ing to-day that the disease belongs to the class of infectious granulo- 
mata, even if the conclusions of Lustgarten and Doutrelepont be not 
confirmed by further experiment, the crucial test being a series of 
productions of syphilis in unmistakably sound individuals, by infec- 
tion with a product of bacilli obtained by cultivation. 

Lustgarten first hardened sections of syphilitic lesions (initial 
chancres, papules, and gummata) in absolute alcohol and colored 
them in a solution of gentian-violet for twelve to twenty-four hours 
at the ordinary temperature and then for two hours at 104° F. The 
sections were decolorized by repeated washings in absolute alcohol, a 
one and one-half per cent, aqueous solution of the permanganate of 
potassium, and chemically pure sulphurous acid. 

It is claimed that by the special method employed, the character- 
istic organisms were always recognized in syphilitic and never in 
non-syphilitic lesions. The bacilli were never free but always 
enclosed in cells of amoeboid movement, resembling lymphoid cells. 
These bodies were straight, curved, or irregularly bent in rod-like 
forms, averaging three and one-half to four and three-tenths of a 
micromillimetre in thickness. Under objectives of low power they 
presented a uniform smoothness with occasional terminal bulbous 
expansions. The surface, however, viewed under a homogeneous 
immersion lens, appeared irregularly undulating and slightly notched, 
the bacillus or rod-like appearance, however, remaining distinct. 
Within each bacillus, separated from each other by spaces of equal 
length, were from two to four bright and colorless spores. 

More recently, however, microorgauisms, similar to those believed 
to be the sources of syphilis, have been discovered in the smegma 
preputii and other secretions obtained from the genital organs of 
non-infected persons of both sexes, thus confirming the belief that the 
specific bacterium of the disease has not been recognized. 

Diagnosis. — The syphilodermata are to be distinguished from all 
other cutaneous eruptions by their general characteristics, and by the 
features peculiar to each lesion. It must not be forgotten, however, 
that these lesions are not essentially different in character from all 
others, but are to be recognized with ease or difficulty, according as 
they do or do not betray the syphilitic expression. No one, however 
expert in diagnosis, can always trust himself to recognize these special 
features by a study of the eruption only, at a given moment of time. 
Neither in respect to color, form, size, situation, disposition, or other 
peculiarity, do the syphilodermata exhibit an absolute difference 
from the non-syphilitic affections of the skin. It is therefore requi- 
site in every case, to investigate in the fullest manner, the history of 



SYPHILODERMA. 529 

the disease, of all prior skin lesions, of a primary sclerosis (when 
this can be obtained), of adenopathy, miscarriages, abortions, and 
disorders affecting other organs of the body, such as the bones, 
viscera, organs of sense, and the mucous surfaces. Often a single 
extra-cutaneous fact will be a valuable aid in establishing the diagnosis 
of syphilis. An "eczematous" infant, with snuffles and a hoarse 
cry, has been treated in vain by many a physician, otherwise capable 
of making a diagnosis, who might have been given a clew to the 
nature of the disease from which the child was suffering, if he had 
taken the pains to inspect the anus and question the father in private. 

It is very necessary in this connection to lay stress upon the well- 
known fact that every syphilitic patient with a disease of the skin 
does not necessarily exhibit syphilodermata. The course of the dis- 
ease is in many cases so protracted that patients have ample oppor- 
tunities to contract other disorders, and their number is larger than 
is commonly supposed to be the case. They suffer most often from 
the medicameutous eruptions, especially those induced by the inges- 
tion of iodide of potassium (q. v.) ; are, like other men and women, 
bitten by bugs and lice ; and suffer from eczema, acne, psoriasis, and 
other non-venereal disorders. This is less true possibly of the inno- 
cent victims of the disease than o± those guilty of sexual excesses iu 
and out of the married state, many of the latter leading the most 
disordered lives, and exposing themselves to the ordinary causes of 
disease to a degree not noted in other cases. 

It is always necessary, therefore, in making a diagnosis in a case 
supposed to be syphilitic, first, to determine ab origine the fact of 
syphilis, and, if that fact cannot be indubitably determined, to be 
careful that the statements of the patient be not allowed to bias the 
judgment in pronouncing upon any eruption present; second, sup- 
posing that such a fact is established by clinical proofs without 
reserve, to determine whether the eruption present is produced by 
the existing syphilis or some other externally or internally operating 
cause ; and if this last be determined, to be careful in eliminating the 
syphilitic influence from its operation. 

Ignored syphilis is usually severe; but it is without avail that 
disorders of a different character are treated by the methods useful 
iu the former. Thousands are annually so mistreated who might be 
spared such a course. The frequent occurrence, after a suspicious 
exposure, of a balanitis, an attack of progenital herpes, uninfected 
excoriations, bleunorrhagic discharges, and even the appearance of 
molluscous tumors, warts, and parasitic cutaneous disorders upon the 
genital region, is a source of alarm and of fruitful error to the many 
rather than to the few. 

On the other hand, the diagnostician must be ever on the alert to 
recognize the symptoms of the disease in those who least suspect it. 
Thus, married women complaining of a " humor of the blood," men 
who have been " over-heated, and broken out with a rash," and. a 
long list of patients exhibiting upon their persons the symptoms of 
"salt rheum," "tetter," "scrofulous ulcers," and "erysipelas" are 

34 



530 DISEASES OF THE SKIX. 

those whose speedy relief will depend upon the skill of the practi- 
tioner in recognizing exactly the precise nature of the malady. 

The diagnosis of the syphilitic lesions of the skin is a matter of 
the very greatest importance, inasmuch as the health, comfort, mental 
happiness, and domestic relations of thousands of men and women 
annually depend upon it alone. An error in either direction may 
involve the most serious consequences to both physician and patient. 
He is but poorly qualified to discharge the important duties of a 
general practitioner of medicine who has not carefully trained him- 
self to establish the truth in these cases, irrespective of the diagnosis 
of the patient, and of all others who may have been consulted. 

Treatment. — The syphilodermata are to be treated by topical appli- 
cations intended to hasten their disappearance or involution, but as 
local manifestations of a constitutional disease, their management is 
largely that which looks to the relief of the latter. 

The treatment of syphilis will, in the pages which follow, be 
described in outline, so far as it relates to the relief of the cutaneous 
lesions and of the systemic condition. The important modifications 
of therapy which are required in the management of syphilis of the 
osseous and nervous system, of the respiratory, gastro-intestinal, and 
other organs, it is scarcely necessary to remark, are fully described 
in the standard treatises specially devoted to this subject. Among 
them may be named, as of American authorship, the sterling works 
of Bumstead and Taylor; 1 of Van Buren and Keyes, 2 and of E. L. 
Keyes. 3 Of those more or less recently published abroad may be 
named the standard treatises of Lancereaux ; 4 of Jullien f of Four- 
nier ; 6 of Diday and Doyon ; 7 of Zeissl ; 8 and of Mauriac. 6 

The first and often the most important consideration for the prac- 
titioner who is in face of a syphilitic patient is the care of that 
patient's general health. Simple and natural as it may be to set 
down such an injunction in this connection, its importance rests upon 
the fact that it is too often neglected. Patient and physician are 
often respectively hurried into the precipitate ordering and swallowing 
of specific drugs, without regard to other as important details. 

The author is in the habit of handing to the patient, at the outset 
of all treatment for syphilis, a slip of paper on which are printed in 
concise and simple terms a set of rules which should be observed 
during its continuance. For physicians who do not take similar pre- 
cautions, it is advisable to enter rather fully into the explanation of 
certain details which the patient should be made to understand. 

He or she, if an adult, should, as a rule, be informed of the 
nature of the disease recognized, since every infected patient has an 
interest in knowing such fact, and it has an important bearing upon 

1 The Pathology and Treatment of Venereal Diseases, Philadelphia, 1883. 

2 A Practical Treatise on the Surgical Diseases of the Geiiito-uiinary Organs, including Syphilis, 
New York, 1874. 

3 The Venereal Diseases, etc., New York, 1880. 

* Traite Historique et Pratique sur la Syphilis, Paris, 1874. 

s Traite Pratique des Maladies Velierietiues, Paris, 1S8G. 

Lecotis sur la Syphilis, etc., Paris, 187:5. La Syph. Ilered. tard., 188G. 

7 Tlierapeutiqne des Maladies V6n£rienne*, Palis, 187U 

s Lelnbuch der Syphilis, etc., Stuttgart, 1875. ° Lecons sur les Malad. Vener., Paris, 1883. 



SYPHILODERMA. 531 

his or her relations to the uninfected. To every such person, with 
the assurance that the disease is often benigu, and productive of 
little discomfort, and in any case curable, it should be stated that the 
affection is contagious, and capable of transmission to sound persons 
by physical contacts of various characters. The patient should be 
instructed as to the nutritious character of the diet he should select, 
and should be informed that an increase in weight, while subjected 
to treatment, is decidedly favorable in the matter of prognosis; that 
the starving and sweating processes so highly esteemed by the char- 
latan and the advocate of the virtues of the waters of certain resorts 
are relics of antiquity, as useless in fact as they are frequent sources 
of peril. 

The bathing of the body is a matter of importance. Hot Turkish 
and Russian baths are, as a rule, to be interdicted, inasmuch as they 
tend to invite cutaneous hypersemia, and thus to favor the occurrence 
of eruptions. Cool or tepid baths are to be employed sufficiently 
often for the purposes of cleanliness, and by the sponge rather than 
by immersion. Dry friction of the surface of the body daily may 
be ordered with advantage where the skin is still sound. The teeth, 
mouth, and gums require constant care. The use of the tooth-brush 
with cool water twice daily is a matter of importance, to be preceded 
for a time, when the gums at the outset are in a tender, fungous, or 
hemorrhagic state, by gentle friction with the finger, covered by a 
handkerchief dipped in a weak spirit-aucl- water lotion, to which the 
tincture of cinchona and of myrrh may be added in any desired pro- 
portion. Tobacco in every form is, without any question, decidedly 
injurious. Often the patient should be sent early to a competent 
dentist for the extraction or filling of carious teeth, and the removal 
by the file or dental engine of all sharp projecting edges. 

Malt liquors, wines, and spirits should be employed solely under 
the explicit direction of the physician. They are exceedingly useful 
in debilitated subjects of a certain class, and need not be unneces- 
sarily prohibited in toto to those long habituated to their use. At 
the same time, an improper use of such stimulants is, it need not 
be said, in the highest degree harmful. When employed at all, 
they should be rigidly restricted to the dining-table and the hours of 
meals. 

A compliance with the laws of hygiene is even more requisite for 
the syphilitic than the nou-infectecl. Fresh air, social amusements, 
exercise, the regular routine of business life, or, when this has 
proved exhausting, the recreation of travel — the claims of all these 
need at times to be urged by the physician. With this the patient 
should be encouraged to free his or her mind from needless anxiety, 
and to avoid particularly the company and conversation of those 
similarly infected, whose opinions are based too often upon ignorance, 
or a knowledge of half truths. The literature of syphilis is, for a 
similar reason, to be eschewed, as the mass of patients, too many of 
whom purchase treatises on the subject, are able only to glean imper- 
fectly the meaning of the authors consulted. 



532 DISEASES OF THE SKIN. 

It should be a rule to urge married patients frankly to inform the 
partner, of the fad of infection, for the sake of both. When this 
advice is followed, much trouble is avoided for the future, and one 
of the obstacles to a completely favorable issue is at once set aside. 
In the author's professional experience, many instances have occurred 
in which the disruption of the conjugal bond resulted from infection 
of one, but usually of both parties; but it is a striking argument in 
favor of the policy here urged, that in this entire experience there 
has been no single instance in which a frank and honorable confes- 
sion has been followed by such a consequence. It should be added 
that in no one of the " confessed" cases has there been subsequent 
infection of the innocent. It need scarcely be said that the larger 
number of these patients have been husbands. Recently infected 
young adults who have contracted a marriage engagement should 
invariably claim release from such a tie for the sake of all con- 
cerned. The syphilitic; nurse must be taken at once from the sound 
nursling, and the child with hereditary syphilis be suckled only by 
its own mother. The latter, according to the law of Colles the 
exceptions to which are so few as to prove the rule, always enjoys 
immunity against the diseased mouth of" her own child. 

Turning to the consideration of the medicaments employed in 
syphilis, it is to be remarked at the outset that there is no routine 
plan of treatment which in every case can be advantageously 
employed. In no respect do physicians so differ from each other, 
judged by the standard of professional skill, as in their ability to use 
a single remedy with success. He who has the largest armament- 
arium is not always either the best equipped or the most successful. 
Mercury, iodide of potassium, iron, and quinine are the great reme- 
dial agents in syphilis, but they may also be used vainly by one man 
in the long effort to accomplish that which another achieves speedily 
and brilliantly by use of the same remedies, emploved with greater 
skill. 

Of the other substances vaunted as either advantageous or specific 
in the treatment of the disease, no one possesses any claim whatever 
to the confidence of physicians. Sarsaparilla, dulcamara, stillingia, 
guiacum, tayuya, mezereon, and the long list of other vegetable pre- 
parations whose virtues have thus been extolled, are all as harmless 
in themselves as they are ineffectual for the relief of the malady. 

Before proceeding, however, to assume the responsibility of 
directing a course of treatment for syphilis with remedies of acknowl- 
edged value, the physician will do well to remember that no two 
cases of the disease are precisely similar, and that there is the widest 
range between the most benignant forms encountered in private 
practice and the malignant cases that are seen in hospital wards. 
Some forms of the malady are so absolutely mild as to constitute an 
inconvenience merely ; others so severe as to destroy life. It is an 
axiom in venereal disease, that more patients perish annually from 
blennorrhagia and its results, than from syphilis. There could be 



SYPHILODERMA. 533 

110 greater error than to treat any disease exhibiting so wide a vari- 
ation in severity, by a uniform method. 

Mercury, after the assaults upon it of generations of men of 
admitted wisdom and candor, stands to-day unrivalled as a remedy 
for the relief particularly of those stages of syphilis in which the skin 
is involved. Administered with skill, it can be given for years at a 
time with immense advantage to the syphilitic, who, during a well- 
regulated mercurial course, should gain in weight, improve in vigor, 
and exhibit a healthier color of the skin. No competent physician 
of to-day employs it in such a manner as to induce salivation or any 
other of its toxic effects. During the last twenty years the author 
has had the opportunity not merely of making large use of this drug 
in his own practice, but of seeing many patients treated by other 
physicians in a similar way. In about a dozen cases there were 
excessive toxic effects of the remedy, and in each the carelessness or 
ignorance of the prescriber was responsible for the result. It should 
be remembered that in every discussion of the merits of mercury in 
syphilis, both physicians and patients have been guilty of the ignor- 
ance or folly of ascribing to the remedy the disastrous effects of the 
disease. 

Mercury may be given by the mouth, by inunction, by subcu- 
taneous injection, or externally by the aid of the vapor bath. Decid- 
edly the most popular method, and that productive of least inconve- 
nience to all concerned, is the method by ingestion. 

In the treatment of syphilis, the mild chloride, corrosive sublimate, 
and bicyanide of mercury, together with blue mass, may be effectively 
employed. These preparations are, however, rather less adapted than 
others for continued employment during long periods of time, and 
are open to the objection of either readily undergoing rearrangement 
into more stable compounds of the metal, or of producing undesirable 
irritative effects. With the protiodide and biniodide of mercury, an 
impression can be produced upon the system which can be readily 
proportioned to the exigencies arising in every case, which can be 
sustained during that "chronic medication" which Fournier declares 
to be requisite in every chronic disease, and which can be exerted 
without fear of immediate or remote deleterious cousequeuces. 

Treatment of syphilis by the mercurial selected for use should, as 
a rule, be begun only at the moment of evolution of constitutional 
symptoms. The initial sclerosis of the disease is, to a remarkable 
extent, amenable to the action of the metal, but in the large propor- 
tion of cases will cicatrize, when in an ulcerative stage, without 
having recourse to general medication. The latter may be well 
reserved, as suggested by Bumstead and Taylor, for such primary 
lesions as are threatening in symptoms, and for such individuals as 
require or demand speedy cicatrization of their chancres, as, for 
example, those about, to travel beyond the reach of medical assistance. 
Personal experience fully confirms the w r isdom of the teaching which 
reserves specific medication till the second period of incubation has 
passed. No local or general treatment can avert either a mild or 



534 DISEASES OF THE SKIN. 

severe explosion of symptoms after that period is completed. In the 
experiments made by the author, in order to determine this point, 
there was either the production of strikingly irritative effects, such as 
very marked relapse, or unusual increase in the volume of the initial 
sclerosis immediately before the evolution of the first syphilodermata, 
or a distinct obstinacy in the latter to the action of the medicament 
employed. 

In the early stages of syphilis in adidts, the protiodide of mercury 
may he named as one of the most trustworthy of preparations. Of 
all classes of adult patients, including strong- males and delicate 
females, there are scarcely two per cent, who cannot take it, if the 
dose he proportioned to the individual susceptibility. It is usually 
administered in pill form, in doses of one-fifth (0.01), one-fourth 
(0.01 (j), or one-third (0.022) of a grain, three times daily, combined 
with the extract of gentian. The dose maybe gradually increased, 
according to the necessities of the case, from one-half (0.032) to three 
(0.2GG), and even four (0.382) grains in the twenty-four hours. 
Many of the gelatine-coated pills found in the market contain accu- 
rately divided doses of the salt. The sugar-coated pills of Messrs. 
Gamier and Lamoureux, containing each one centigramme of the 
protiodide, are efficient, and largely employed. 

Commencing with a minimum dose, the remedy is to be steadily 
exhibited, and the daily quantity consumed very gradually increased, 
till the degree of tolerance of which the patient is capable has been 
ascertained. Should the stools become frequent, pain be excited, or a 
slight effect be produced upon the mouth, such as is indicated by a 
metallic taste, moderate increase in the quantity of saliva, or any 
noticeable degree of tenderness of the gums, the dosage is to be grad- 
ually diminished till these symptoms disappear. Often the with- 
drawal of a fifth (0.01) or a half (0.032) of a grain daily, will suffice 
to enable the patient to tolerate the quantity thus diminished. The 
medication is to be faithfully continued till the object in view is 
obtained, viz., relief of all symptoms of the disease. 

K eyes' s well-known, so-called "tonic treatment of syphilis" is 
based largely upon the plan whose outline is merely sketched above. 
By the method which this author has certainly popularized, the 
dosage is increased only on each third or fourth day, till irritative 
effects are produced, when, after an interval of two days, the quantity 
taken at the time of the production of such effects is reduced one-halt 
to one-third. This reduced quantity is termed the "tonic dose," and 
is thereafter continued throughout the treatment in "nearly all condi- 
tions of health or disease." 1 

This method of treatment is in many cases admirably effective and 
is eminently safe. Still, viewing the subject with the conservatism 
which its importance justifies and which a mass of clinical facts 
demands, it may be well doubted whether it is always proper to 
administer a mercurial for weeks at a time to a man in apparently 

1 Consult the interesting paper of the author in the American Journal of the Med. Sci., January, 
1876 ; also his latest exposition of his views in the Philada. Med. Times, November 25, 1882, p. 3j7. 



SYFHILOJJERMA. 535 

good health. With the active measures at immediate control in the 
mercurial vapor bath, it is usually safe and not unwise to suspend tem- 
porarily specific medication of the patient who exhibits such ameliora- 
tion of symptoms as to be free from external manifestations of the 
disease. Every syphilis has its periods of activity and repose. Such 
an hour of repose will be well employed in the administration of iron, 
which, as tending to relieve the distinct chloro-ansemiaof the disease, 
has its claims to recognition in the list of " specific" remedies. No 
case of syphilis can be said to have been properly treated, in which 
this remedy has not been given for at least a part of the time during 
which the patient was under observation. The citrate of iron and 
quinia is an excellent preparation for this purpose, administered at 
the meal hours, in a small quantity of sound sherry wine ; or the 
iodide of iron may be employed in syrup, or in the pills made by the 
formula of Blancard, or in Vallet's mass. In other cases, the 
muriated tincture may be employed, but the physician will always be 
cautious about ordering an acid preparation of any kind during the 
intervals of a mercurial course. There is no form of anaemia which 
responds more promptly to the chalybeates than does that produced 
by the syphilitic virus. 

The biniodide may be substituted for the protiodide when, for any 
reason, it may be thought desirable, commencing with a minimum 
dose of one sixty-fourth of a grain (0.001), aud increasing this 
gradually to one-fortieth (0.0016) or rarely to one-twentieth (0.0033), 
either in pill or solution. The average dose of one-fortieth (0.0016) 
of a grain in pill form, administered three times daily, soon after 
eating, is tolerated by the majority of all patients of both sexes 
without consciousness of unpleasant effects. 

For those who prefer to use the rather more active and correspond- 
ingly dangerous salts of the metal, calomel may be administered in 
one or two grain doses (0.066-0.133) three times daily, in combina- 
tion with an opiate to prevent its action on the bowels, or, as recom- 
meuded by Peters, in one-tenth (0.0066) of a grain dose every hour. 
Small doses of blue mass or gray powder may also be employed. 
According to the traditions of the profession, the gray powder is 
most suitable for children and infants, but since the frequent 
discovery in the latter of the corrosive chloride, either as of early or 
late chemical production, it is less esteemed. The homoeopathic first 
decimal trituration of calomel with sugar of milk, is a far more 
suitable compound. Corrosive sublimate in doses of from one- 
twentieth (0.0033) to one- twelfth (0.005) of a grain is exhibited in 
pill form or in solution ; and is probably more generally employed in 
the treatment of syphilis than any other mercurial salt. The objec- 
tions to its use are suggested above. Though constantly employed 
in the public charities, where it is furnished as a cheap and a con- 
venient substitute for the more elegant preparations in the market, 
it is much less frequently ordered for syphilitic patients in private 
practice. When given in solution, it produces a disagreeable metallic 



536 DISEASES OF THE SKIN. 

taste iii the mouth, which some patients ran perceive after the lapse of 
six hours. 

With many authors of wide experience, it is customary to employ 
opium, cither alone or in connection with the use of mercury, for the 
relief of ulcerative or other lesions of syphilis. Sometimes it is 
employed for the purpose of relieving pain, sometimes to prevent the 
cathartic, action of the metal upon the bowels, and again because it is 
supposed to possess some power of arrest over the destructive action 
of the disease. It should not, as a rule, be exhibited when by 
reducing the mercurial or exchanging the latter for a ferruginous dose, 
the same result can be reached. Few syphilitic patients are in the end 
brought to the desired termination of the disorder, by the use of a 
remedy which interferes with assimilation and digestion; and such a 
remedy is opium in all its forms. Temporary advantage is often 
gained by its employment, but this may be more than counteracted 
by it- ultimate effect upon the gastro-intestinal tract. 

Mercury is also satisfactorily introduced by the method of inunc- 
tion. The metal, when thus employed, is readily absorbed by the 
system, and its therapeutic value is no less evident. Inunction 
should be employed in every case which admits of it, since the gastro- 
intestinal tract is thus left undisturbed, and, further, the dose of any 
needed chalybeate or the iodide of potassium per os, can be regulated 
without increasing or diminishing the quantity of mercury in daily 
use. Mercurial ointment is commonly used for this purpose, but a 
much more cleanly substitute for it, is provided in the oleate of 
mercury in the strength of ten, fifteen, or twenty per cent. There is 
but little question that the oleate also is somewhat more readily 
absorbed from the surface of the skin. The ten per cent, oleate is 
in general to be preferred to the stronger preparation, as less liable 
to irritate the surface of the skin. From half a drachm to a drachm 
(2.-4.) of either the ointment or the oleate can be rubbed into the 
skin at night before retiring, and the part selected for inunction 
cleansed by washing in the morning. Both, if continuously applied 
to a single portion of the skin, are liable to produce a mild local 
dermatitis or eczema, and hence it is wise to select on successive 
evenings a fresh portion of integument for the local application, 
preferably that where the epidermis is relatively thin, as, for example, 
the flexor aspects of the joints. The patient can thus upon one 
evening anoint the internal faces of the thighs; upon the next, the 
sides of the chest; upon another, the loins, etc., taking care to 
avoid surfaces where an induced eczema is likely to prove especially 
annoying, such as the scrotum, the axilla?, and the groins. The 
oleate may in some cases be well rubbed into the soles of the feet 
previously soaked in warm water, after which the socks or stockings 
may be drawn over the feet for the night. In the case of infants, the 
inunction is well performed by the natural movements of the child, 
if a flannel swathing-band previously smeared with the oleate be 
wrapped about its belly, so that the mercurial comes in contact with 
the skin. Should local irritative effects be produced, these subside 



SYPHILODEEMA. 537 

rapidly, as a rule, after a warm alkaline ablution followed with a 
bland dusting powder. Subsequently or even before such accident 
in the case of infants or patients having unusually sensitive skins, the 
oleate may be mixed with equal parts of vaseline, lard, or olive oil. 
As some patients become disgusted with this routine, it is well at the 
onset to flavor the substance selected for inunction with lavender, 
rosemary, or bergamot. 

In this country too little attention has been attracted to the treat- 
ment of syphilis by mercurial inunction. With this in view the pre- 
ceding paragraphs which describe the use of mercury by the mouth 
are to be understood as related in all cases to the employment of the 
metal by the skin. It is well to order inunction in all practicable 
cases; to save the stomach as much as possible; to continue with the 
oleate nightly, weekly, or less frequently so long as there is danger 
of relapse ; and to adjust carefully the quantity employed to the 
exigencies of every case. In this manner patients may be relieved 
of all symptoms of the disease who have not during their treatment 
swallowed a single dose of mercury, and the permanency of whose 
relief may be tested during years of subsequent observation. 

One of the most effective methods of administering the metal is 
by fumigation, in the mercurial vapor bath. It is employed by many 
syphilologists as the sole means of exhibiting the mercurial selected 
for use, but is, for the average of American patients, too inconvenient 
for continuous employment. It should be regularly employed first, 
in all cases where the earliest syphilodermata are intense, generalized, 
and particularly conspicuous upon the face; second, in all obstinate 
cases where the patients are not women nor cachectic subjects of 
either sex; third, at the outset of many ''ignored" cases, where the 
syphilodermata, either more or less generalized, have proceeded to unin- 
terrupted evolution; fourth, in the severe cases of patients coming 
from the country to the city, and able to remain but a brief time 
within reach of the advantages offered in the metropolitan centres. 
From half a drachm to a drachm (2.-4.) of calomel, metallic mercury, 
the bisulphuret, the black oxide, or the hydrargyrum cum creta, may 
be employed for each bath. It is common to order from a scruple 
to a drachm each (1.-4..) of calomel and cinnabar. The patient is 
stripped of his clothing and seated in a chair, the patient and chair 
being completely enveloped in blankets, which are closely fastened 
at the neck of the bather. Beneath the chair is an alcohol lamp, sur- 
mounted by a tin vessel containing water in ebullition, the hot vapor 
of which in a few moments induces copious perspiration. When this 
result is obtained, the lamp is brought beneath a metal plate containing 
the substance to be volatilized. The patient remains exposed to the 
vapor about ten minutes after this process of sublimatiou is finished, 
and retires at once to bed without cleansing the skin, the fumigation 
being preferably conducted before the hour of sleep. In the morning, 
a bath may be taken for the purpose of cleanliness. It is more con- 
venient in the generation of the vapor in this way, to make use of 
Mr. Henry Lea's safety fumigating lamp, but the materials requisite 



533 



DISEASES OF THE SKIN. 



for the production of all desired effects, with the exception of the 
alcohol lamp, can be procured of any good tinsmith. In the city, 
male patients arc often sent to the bath-houses, where the fumiga- 
tion is conducted in the daytime; and rarely experience as a con- 
sequence unpleasant effects, such as arc popularly associated with 
"taking cold" after exposure to the action of mercury. In the most 
of these establishments, provision is made so that the head also can 
be exposed to the mercurial fumes, respiration being conducted 
through a tube in connection with pure air, a provision useful in cer- 
tain cases of emergency; and only "emergency cases" should be 
required to resort to such measures. 



Fig. 68. 




Lea's lamp fur fuaiigat 



The happy effect of the mercurial vapor bath is often marvellously 
rapid. A generalized syphiloderm may become well-nigh indistin- 
guishable upon the surface after four baths at intervals of two days 
each. With this potent agency at hand, it can be well understood 
how the skilled physician can afford to watch his syphilitic patient 
from week to week, taking a dose of iron internally and employing 
inunction externally, the few lesions fading slowly from the surface, 
all fears quieted, and the nutrition sustained at a high grade. In 
comparison with this combined method, the swallowing of blue mass, 
or calomel and opium, should be regarded as a more clumsy and 
dangerous procedure. 

The hypodermatic injection of mercury, largely popularized by 



SYPHILODERMA. 539 

Lewin, 1 though very frequently employed in Europe in the treatment 
of syphilis, is open to the serious objection of requiring the aid of the 
physician for the administration of each dose. It is an efficient, 
speedy, and safe method, but will probably always find largest favor 
in the treatment of patients in hospital, who are there completely 
subject to the orders of their medical attendant. At the site of the 
injections, too, not rarely abscesses have formed. One-twelfth (0.005) 
or one-eighth of a grain (0.008) of corrosive sublimate, dissolved in 
ten or fifteen minims of distilled water may be injected at a time, the 
operation being repeated upon about twenty occasions. Bamberger, 
of Vienna, has reported favorable results after the injection of an 
albuminate or a peptone of mercury, thus attempting to avoid the 
danger of localized abscesses, and insuring speedy absorption of the 
metal. All formulae, however, proposed for preparation of solutions 
of this character have hitherto proved imperfect, both in consequence 
of failure to obtain a pure mercuric albuminate, and also from failure 
of permanency in the solution. Staub's formula, the result of experi- 
ments made by Hepp, 2 may be taken as a sample of the rest : 

Hydrarg. clilorid. corros. gr. xviij ; 1 25 

Ammon. chlorid. gr. xviij ; 1 25 

Sod. chlorid. 3j ; 4 

Aq. dest. fgiv; 128 M. 

Dissolve, filter, and add the white of one egg in distilled water suf- 
ficient to make (128.) ^iv; fifteen minims of the solution contain 
about one-twelfth of a grain (0.005) of the sublimate. 

Ptyalism, stomatitis, fetor of the breath, or a fungous condition of 
the gums with inappetence and other characteristic symptoms of the 
ill effects of mercury, including all grades of gastro-intestinal disturb- 
ance, are rarely seen in modern practice, and should never be per- 
mitted to occur in a properly regulated mercurial course. When they 
are produced, the tongue projected from the mouth is usually tumid, 
and exhibits at its lateral borders the imprints of the inner faces of 
the molar teeth. Its surface is also covered in various degrees with 
a thin, dirty-grayish coat ; and the odor of the breath is peculiarly 
offensive, being often noticeable at a distance of several feet from 
the patient. In such cases, the food should be liquid and nutritious; 
hot and cold drinks alike should be scrupulously avoided; and the 
mouth frequently cleansed with washes containing dilute liquor sodas 
chlorinatse, or the chlorate of potassium, or very weak carbolic acid 
in solution. Internally, the citrate of iron and quinia may be often 
used with advantage ; and, in particularly severe cases, the chlorate 
of potassium to the extent of a drachm (4.) daily. The compressed 
tablets of this salt, each containing five grains (0.33), are available 
for this purpose, being slowly dissolved in the mouth, the medicated 
saliva and mucus being then well diffused over the inflamed buccal 
membrane, tongue, and fauces. The mercurial is to be suspended in 

1 Die Behandluna: der Syphilis mit Subcutaner Sublimat-injection, Berlin, 1869 ; also translated by 
Prceglerand Gale, Phila., 1872. 

2 Traitement Ue la Syph. par les Inject. Hypoderm. de Sublime. These de Paris, 1872. 



540 DISEASES OF THE SKIX. 

all cases, and iced water to be interdicted, gangrene having followed 
it- use in a few cases. In milder forms, the tincture of myrrh and 
of cinchona, diluted with sweetened water, or honey and water, will 
be sufficient for local medication of the mouth. 

Iodine is chiefly employed in syphilis in the form of the iodide of 
potassium. It possesses some value, without any question, in every 
stage of syphilis, and is thus indiscriminately used by many practi- 
tioners. Its value, however, in late secondary and tertiary, is ineon- 
testahly greater than in the earlier lesions of the disease, and its use 
should lie largely restricted to the particular periods in which these 
manifestations appear. Every prudent physician will hesitate before 
ordering, for a disease exhibiting cutaneous lesions, a remedy which 
will positively produce cutaneous lesions in the majority of all 
patient- ingesting it. In this connection the reader will do well to 
consult the chapter on dermatitis medicamentosa, in which the 
various eruptions produced by this drug are recorded. Thoughtful 
men are beginning, in the light of the present knowledge upon this 
subject, to ask, to what extent the syphilodermata have beeu in the 
past aggravated or obscured by this remedy. He would be indeed 
bold who would attempt to prove that the medicamentous eruptions 
thus excited have not, in the past, figured largely in the catalogue of 
the syphilodermata. 

On the other hand, the value of the remedy, properly adjusted to 
the age and other conditions of the disease, is more than incontestable, 
it is peerless in it.- special field. Whether given alone ; or by the 
so-called "mixed" treatment in combination with mercury; or admin- 
istered internally while a mercurial is introduced by the skin ; or 
exhibited, lastly, by alternation with the metal, in each it finds a 
special value, and may be simply indispensable. It may be given in 
doses of from five grains (0.33) to a drachm (4.) three or four times 
daily after eating, well diluted with water. The larger doses should 
be invariably reached gradually ; should never be employed except 
by special order of the physician, and when the patient is within easy 
reach of the latter ; and should always be ordered with the under- 
standing that the patient should diminish or suspend treatment in 
case of unpleasant results. The symptoms of iodism, other than the 
production of cutaneous lesions, such as coryza, oedema of the lids, 
and faucial irritation, are apt to be the result of the first few doses 
ingested, and often bear no relation to the size of the latter. One 
or two grains (0.66-0.133) will, in certain cases, be sufficient to 
produce the most disagreeable effects which, if they are observed 
before the remedy be suspended, may not return with even the largest 
doses. In a few cases, the iodide of potassium produces violent toxic 
effects in any dose, owing to exceptional idiosyncrasy. The author 
has met with several such cases, and has had one patient in his 
charge suffering from an ulcerative tubercular syphiloderm of the 
nose, who was quite unable to tolerate the drug in any form. Both 
the chloride of ammonium and carbonate of ammonium are recom- 
mended for use in combination with the iodide of potassium, as 



SYPHILODERMA. 541 

increasing its efficiency. The iodides of sodium, ammonium, and 
lithium possess also, without question, some influence over the disease, 
but are for most cases less efficacious than the potassium salt. Of the 
three named above, the iodide of lithium is apparently most prompt 
in its effects. 

There is no combination of mercury with the iodide of potassium 
which is employed more frequently than the well-known "sirop de 
Gibert," which though first popularized in the St. Louis Hospital, of 
Paris, has been since extensively employed in this country. It has 
been slightly modified to suit the varying tastes of many surgeons. 
It is often ordered in the following!; formula : 



R. Hydrargyri biniodid. gr. ss-ij ; 

Potass, iodid. Sy-viij; 8-32 

Gentian, syrup, (vel ] 

syrup, glycyrrhiz.) > aa 13 ij ; 64 

Aq. dest. J 

Dose. A teaspoonful in water after eating. 



033-.13 



M. 



The syrup of liquorice disguises the taste of this combination better 
than most of the other syrups used. With the dosage carefully regu- 
lated, a few drops (ten to fifteen) may be administered with advantage 
to children. 

The following are indications for the use of the iodide of potassium 
either alone or by the so-called "mixed" method in the treatment of 
syphilodermata : The occurrence (1) of late, tubercular, gummatous, 
or ulcerative lesions ; (2) of formidable symptoms in other portions 
of the body concurrent with early or late, mild or severe syphilo- 
dermata, as, for example, grave ulcerations of the velum or fauces 
with a symmetrical macular eruption, or coincidence of a generalized 
pustular or papular syphiloderm with hemiplegia, aphasic, ocular, or 
renal complications ; (3) of early or late manifestations which either 
assume the so-called "galloping" type, being rapidly succeeded by 
more and more formidable symptoms, or which exhibit the capricious- 
ness of the disease in a reversal of the usual sequence of evolution, as, 
for example, when symptoms usually counted as late phenomena, 
occur within a few weeks after infection and are followed by the early 
symmetrical rashes ; (4) of early or late symptoms occurring in 
cachectic, strumous, or otherwise debilitated patients. The author 
has treated eleven tuberculous patients infected with syphilis ; and 
this experience has led to the belief that in all such cases it is imper- 
ative to dispense with every mercurial dose possible. Mercury is 
assuredly not a tonic in tuberculosis commingled with syphilis. 

The local treatment of the initial sclerosis of syphilis by complete 
excision, lately revived by Auspitz, has been practised since the date 
of his paper in 1879, by Kolliker, Zeissl, Leloir, Chadzynski, 
Mauriac, and others ; l and the result has proved conclusively that 
such operative interference furnishes no bar to constitutional infec- 
tion. Chancres should not be destroyed by caustic agents of any 

1 See Keyes's later communication on this subject, 1. c. 



542 DISEASES OF THE SKIN 

character, as the latter arc liable to induce either irritative or inflam- 
matory effects which may be followed by denser induration. Oint- 
ments, as a ride, are also objectionable, exception being made in the 
case of haemorrhagic lesions when the removal of an adherent dressing 
is liil lowed by unpleasant consequences. Cleanliness with soap and 
water is of chief importance. After each local bath the parts; may 
be dusted with a dry powder such as iodoform, iodol, calomel, zinc 
oxide, bydronaphthol, or starch ; or dressed with a soft piece of lint 
saturated in the lotio nigra, or even better a spirit lotion containing 
tannin and carbolic or boric acid. Opiated washes may be requisite 
in all painful and ulcerative lesions. When a phagedenic tendency 
is displayed, deep cauterization may be required; and the subsequent 
local employment of solutions of the potassic permanganate, two to 
ten grains (0.133-0.666) to the ounce (32.) of water. 

When a primary venereal sore of any character (the initial sclerosis 
of syphilis or the chancroid) actually falls into gangrene or becomes 
phagedenic or, even in the absence of both of these calamities, extends 
rapidly in depth or in superficial area, cauterization should not be 
longer tried. The most effectual treatment of these complications in 
the genital region, is by the employment of the continuous hot water 
bath, aided by antisepsis. The patient remains seated in the bath 
(the water being of the temperature most grateful to the surface and 
with great care maintained at that degree of heat) throughout the 
day, or, in formidable emergencies, if carefully watched, by day and 
night. The bath is left by the patient only for the purpose of 
evacuating the bladder or rectum. Granulation and repair speedily 
set in. The parts are well dusted with iodoform or iodol, whenever 
the patient leaves the water. By this invaluable means, the author, 
in both hospital and private practice, has succeeded in obtaining 
cicatrization of extensive ulcers which had reached over the penis 
halfway to the pubic region. 

Local treatment of the syphilodermata may be demanded, either 
by reason of their appearance on exposed surface, such as the face and 
hands, or by reason of their obstinacy or threatening character, as 
when they are ulcerating rapidly. Macular and papular lesions of 
the face may be treated by local applications of the live per cent, 
oleate ; mercurial ointment, one to two drachms (4.-8.) to the ounce 
(32.) of cold cream or vaseline ; the red oxide, two to four grains 
(U.133-0.266) to the ounce (32.); or the ammonio-chloride, half to 
one scruple (0.666-1.33) to the ounce (32.) of ointment. Lotions of 
the bichloride, one to two grains (0.066-0.133) to the ounce (32.) of 
cologne, are also efficient. These preparations will be found much 
more valuable if used at night before retiring, and left upon the face 
during the hours of sleep. Each is well preceded by hot bathing of 
the face for several minutes, as in the preparatory treatment of the 
same region in acne papulosa, and indeed the sulphur preparations 
employed for the relief of that disease, will at times be found useful 
also in the local treatment of the syphilodermata. 

The hot ablution is particularly useful in the treatment of the 



SYPHILODERMA. 543 

scaling and frequently fissured lesions of the palms and soles, the 
pain of which in severe cases, is greatly alleviated by this treatment. 
After the epidermis in these parts has been well macerated, the hands 
or feet should be thoroughly dried, and the mercurial, tarry, or other 
salve well rubbed in. The glove or stocking should be then drawn 
over the part. 

Secreting condylomata, flat papules, vegetations, etc., also require 
bathing in soap and water, especially when situated at the mucous 
outlets of the body or on the scalp. When the secretion is offensive 
carbolic acid, thymol, or chlorinated soda should be added to the 
lotion. Cleanliness is indeed more essential to the syphilitic patient, 
man or woman, than to the healthy. After such cleansing or disin- 
fecting ablution, the parts should be dressed with a powder, such as 
dry calomel, iodoform, iodol, hydronaphthol, bismuth, the zinc oxide, 
salicylate of soda, or starch. Vegetating lesions of these regions may 
require also pencilling "with a crayon of the nitrate of silver. Oint- 
ments, as containing grease, are decidedly objectionable for this purpose. 

Crusted and ulcerative lesions, large or small, are to be treated in 
accordance with general principles. Crusts should always be 
removed, either by the oil and soap and water treatment, or by the 
dermal curette, after which the underlying ulcers should be thoroughly 
cleansed, pencilled with nitrate of silver, filled with powdered iodo- 
form, iodol, or calomel, or touched with a five to twenty per cent, 
solution of carbolic acid, and then dressed with a dilute ointment of 
the nitrate of mercury, one to two drachms (4.-8.) to the ounce (32.). 
Large syphilitic ulcers are often encountered on the surface of the 
lower extremities, especially the legs, and in this situation elastic 
compression by the rubber bandage will greatly accelerate their cica- 
trization. 

The syphilodermata are in general particularly amenable to the 
action of the mercurial vapor bath, which may be regarded as exert- 
ing upon them both a local and constitutional influence. Those 
existing upon the face are thus benefited by exposure to the metallic 
vapor in the " head-piece" arrangement already described. The 
patient may also less comfortably avail himself of the same local 
treatment, by holding the breath and exposing the head and face for 
a few minutes at a time to the fumes of the mercury beneath the 
blanket, in the plan described as practicable at the bedside. 

It is within reasonable bounds to say, that the syphilodermata, if 
treated locally by the measures described as useful in non-syphilitic 
cutaneous affections of similar type, will always proceed to a satis- 
factory involution, if the general treatment of the patient is at the 
same time skilfully ordered. 

Prognosis. — The prognosis of syphilis may be said to be in general 
favorable, the popular opinion on the subject being at variance with 
fact. Benignant syphilis may even disappear without treatment. 

Malignant forms of the disease may, but rarely do, destroy life. 
The element of treatment, both as to the character of the latter and 
the period of its continuance, enters more largely into the estimate 



544 DISEASES OF THE SKIN. 

upon which a prognosis rests, than in most other disorders exhibiting 
cutaneous symptoms. The syphilis which is untreated, whether 
because of a failure to recognize its real character, or of ignorance, 
poverty, neglect, or extravagance in dissipation, is usually grave. 
The same may be said of syphilis occurring in strumous, tuberculous, 
and cachectic subjects, those enfeebled by age, by other diseases, by 
chronic alcoholism, or by sexual excesses. Hereditary syphilis is by 
far the graves! form of the malady, not merely because of the tender 
age of its victims, but also because the latter, at the earliest period of 
their lives, find themselves burdened by a disease which may first 
attack organs essentia] to life. 

The majority of adult American patients sooner or later get rid of 
all active manifestations of the acquired disease, marry, and beget in 
the end sound children. 

Chancroid. 

This term has been very generally adopted in this country for the 
purpose of designating the virulent, local, contagious ulcer of the 
geuitals, designated also as the " simple," " soft," " non-infecting" 
chancre, the chancreUe of French authors. It has no relation to 
syphilis, nor to the neoplasmata with which syphilis is commonly 
classified. As it is, however, a disease with which the initial sclerosis 
of syphilis may be confounded, and is also, not merely a venereal 
lesion, but one which may be encountered upon the skin as well as 
the mucous surfaces, it is briefly described in this connection. 

Chancroids present as distinct a uniformity of feature as the lesions 
of vaccinia or of herpes zoster. They are thus stamped with special 
and readily recognized characteristics, differing in this respect from 
the various modes in which the first lesion of syphilis may declare 
its nature. The virus of the disease, for such it must be termed, 
is one sui generis, and derived exclusively from lesions of like 
character. That virus is contained in a purulent secretion, and is 
capable of transmission by inoculation and auto-inoculation. After 
such successful inoculation, there is no period of incubation. The 
results of experimental generation of the virus in human subjects, 
indicate that the pathological process which it awakens can be 
determined within twenty-four hours after its introduction within 
the skin. At times, after accidental inoculation, eight and ten days 
elapse before the lesion of the disease is manifested, cases where pre- 
sumably the virulent secretion has remained pocketed in the orifice 
of a follicle or a fold of mucous membrane, where its irritant effects 
have finally opened an avenue for its deeper ingress. When typically 
developed, the chancroid is seen to be a pustular lesion, frequently 
multiple, of roundish outline, beginning as a pin-head sized, turbid, 
vesico-pustule, rapidly enlarging to a pea- or bean-sized, well 
developed, projecting, yellowish, globoid, elevation of the epidermis, 
filled with greenish-yellow pus. When located in furrows or depres- 
sions of the surface, it may have a linear, oval, or even a dumb-bell 



CHANCEOID. 545 

shape, the latter in consequence of its extension from a sulcus to over- 
lying folds. 

Clinically, the roof-wall of this pustule is not frequently encount- 
ered, the lesions from the first exhibiting the ulcers from which the 
pustules described above invariably rise. These ulcers vary with 
the shape of the superimposed pustules, being round, ovalish, or 
linear, occasionally irregular in outline, with sharply defined or cut 
edges; uneven, pus-bathed floor; faint pinkish areola; supple, non- 
indurated base ; abundant puriform secretion ; and are accompanied 
by pain or not, according to the degree of inflammation present. In 
consequence of the auto-inoculability of the discharge, the ulcers 
frequently give rise to others in the vicinity, as when the prepuce lies 
in contact with chancroids of the glans. 

The ulcers thus presented usually attain an average size of a pea 
or bean in the course of from ten to fourteen days; then remain in 
an indolent and suppurative condition, showing no tendency to heal 
for a fortnight or three weeks; and finally granulate, exhibiting the 
ordinary phases of repair; the resulting cicatrix being transitory 
or, more often, indelible. In exceptional cases the ulcer spreads 
widely. In the groin, it may attain a diameter of several inches; 
its floor secreting scantily; its edges, lurid, undermined, purplish, or 
ragged ; its color, reddish, bluish, purplish, or leaden ; fistulous tracts 
and sinuses filled with an ichorous sero-pus, radiating in dependent 
situations ; its base, densely indurated ; its career, prolonged for years, 
and inducing finally a systemic cachexia not different from those 
observed in all chronic ulcerations of severe grade. In yet other 
cases, the occurrence of gangrene, or phagedena, changes the features of 
the lesion to those of other ulcers undergoing similar metamorphosis. 

Chancroids occur upon all exposed mucous surfaces of the geni- 
talia of both sexes, upon the integument of the penis, scrotum, labia, 
thighs, fingers, perineum, peri-anal region, and, very rarely indeed, 
upon the face. In consequence of their tendency to relapse, abundant 
contagious secretion, and auto-inoculability, they are more frequently 
encountered than the primary syphilitic lesion, among the filthy, 
the poor, and the classes that frequent hospitals and dispensaries. 
Among the wealthy, the well-to-do, and the cleanly, this order of 
frequency is reversed. 

The chancroid ulcer is also much more frequently complicated by 
surgical accidents than is the infecting lesion of syphilis. This is 
partly due to the prevalence of an ulcerative type in all its manifesta- 
tions, and in part to its situation. Thus it is often accompanied by 
severe inflammatory symptoms, which may be aggravated both by 
phimosis and paraphimosis, occurring with stenosis of the preputial 
aperture, or with a long, lax, and redundant foreskin. Phagedena is 
also a formidable complication, whether of sloughing or serpiginous 
tendency, the lesion in each case losing its chancrous characteristics. 
It is evident also that the disease may coexist with others of a different 
character. Thus a single point may be simultaneously inoculated with 
chancroidal and syphilitic virus; the former, without an incubative 

35 



546 DISEASES OF THE SKIN. 

period, followed rapidly by a pustular or ulcerative lesion; the latter, 
after its incubation is complete, producing the characteristic symptoms 

of an initial sclerosis. Chancroids may also be found coexisting with 
secondary and tertiary syphilitic lesions of the genitals, with vegeta- 
tions, with blennorrhagic discharges and balanitis, with pediculi of 
the pubes, and with herpes progenitalis. Patients of the class exhib- 
iting these lesions, not infrequently present themselves at public dis- 
pensaries with three or more of these concurrent disorders. 

One of the most serious complications of the chancroid is its 
association with a specific lymphangitis, peri-adenitis, or adenopathy. 
Tn such case, the lymphatic trunks connected with the lesion become 
inflamed, indurated, and irregularly corded, with the overlying 
integument often oedematous, reddened, and painful. The chancrous 
process in these vessels rarely terminates by suppuration. The bubo 
of chancroid is more common, and may be either a sympathetic 
adenopathy, resulting from the severity of the process at the site of 
the lesion, or virulent and due to the transmission of an inoculable 
pus to one or more of the glands in near connection with the source 
of the trouble. These gland complications may coexist in one person, 
in men more often than in women, and in about .one of each four or 
five cases presented to observation. When inoculable pus has been 
formed in a neighboring gland, the latter is at once converted into 
the seat of an abscess, the pus of which, whether evacuated sponta- 
neously or by the knife of the surgeon, speedily inoculates the lips 
of the wound through which exit has been obtained. The wound 
and contiguous abscess cavity then form a large chancroidal ulcer, 
usually inguinal in situation, as the glands in this locality are 
nearest the most frequent seat of the lesion. Such an inguinal ulcer 
discharges a greenish-yellow pus, often commingled with blood; its 
borders are undermined, thin, livid or purplish, and ragged; its 
floor is irregular, sloughy, and often covered by nodules representing 
the debris of glandular structure; from it depart sinuses traversing 
the tissues in the vicinity, often downward to the thigh, occasionally 
upward over the belly. When occurring in strumous and cachectic 
subjects, or when long neglected or mismanaged, the resulting dis- 
order is one of the most serious character, and may surpass in dura- 
tion and severity certain of the varieties of lupus and epithelioma. 
The author has had under his charge a man, the skin of whose right 
thigh, from the groin to the knee, was completely riddled by sinuses 
resulting from a chancroidal bubo which had occurred several years 
before. A few years ago, the author was called in consultation to visit 
a woman in wretched health with an indolent ulcerative lesion of this 
sort in the right groin, which had lasted for five years. Despairing 
of relief, and before a change of treatment could be instituted, she 
hanged herself by the neck till she was dead. 

Facts of this sort have an important bearing. It is true that 
syphilis is a constitutional disease, and usually occurs but once in a 
lifetime. It is equally true that the chancroid is the evidence of a 
local and non-systemic disorder, producing constitutional effects only 



CHANCROID. 547 

as may all other local affections of chronic course and severe grade. 
But it is a grievous blunder to suppose for these reasons, that the 
latter is the milder of the two maladies. Many of its consequences 
are very much more severe, and some of them even more malignant, 
than the average of syphilitic explosions, and even, as indicated 
above, worse than some forms of other diseases usually counted as 
malignant. Greater attention should be generally directed to the 
truth respecting the comparative gravity of the two diseases, as there 
is widespread ignorance of the real fact. 

Chancroid is to be distinguished from syphilitic chancre, but no 
skill, however great, and no experience, however wide, will enable 
the diagnostician, even when typical chancroid is present, to assert 
that syphilis will not follow, until the longest incubative period of 
the initial sclerosis of the last-named disease has elapsed without 
production of suspicious symptoms. The rule which necessarily fol- 
lows is imperative, and, being too frequently ignored, a great deal of 
bitter disappointment on the part of the infected individual, and of 
keen mortification on the part of the physician, has naturally resulted. 

NO PATIENT SUFFERING FROM A CHANCROID CAN BE SAFELY 
PROMISED IMMUNITY AGAINST SYPHILIS, TILL TWO MONTHS AND 
A HALF HAVE ELAPSED SINCE THE DATE OF LAST EXPOSURE. 

Subject to this essential reserve, the diagnosis rests upon the pustular, 
ulcerative, and discharging features of the chancroid, its failure to 
indurate at the base, its auto-inoculability, its appearance without 
previous incubation, its more formidable localized expression of 
disease, and the characteristics of the accompanying adenopathy. 
The short-lived, superficial vesicles of herpes progenitalis, often 
accompanied by tingling and painful sensations, with sequela? in the 
form of equally superficial, epidermal excoriations, are not to be con- 
founded with chancroids ; and yet it must be remembered that these 
lesions may also precede or accompany any form of venereal disorder. 
Chancroids are also to be distinguished from secondary and tertiary 
lesions of the genitals, and from n on -syphilitic vegetations and 
molluscum epitheliale of the same region. 

The pathology of the chancroid, though illustrated by the researches 
of Biesiadecki, Auspitz, and Unua, is yet not understood to an extent 
that will explain its specific character. Anatomically, there is disclosed 
by the microscope a uniform, dense infiltration of the corium with 
elements which undoubtedly represent inflammatory metamorphosis 
of the connective tissue of the derma; degenerative changes where 
the ulceration has proceeded superficially; enlargement of vessels. 
from thickening of their walls, often with diminished lumen ; and' 
relatively intact rete and corium at the lateral borders of the ulcer. 
This fully confirms the inferences suggested by a clinical study of 
the disease., Many roundish, circumscribed, clean-cut ulcers with 
purulent floors occur upon the skin, which bear no relation to the 
chancroid disease. It is the history and career of the latter, which 
stamp it with an individuality of its own. It is not the form and 



548 DISEASES OF THE SKIN. 

appearance of its pus elements, but their power and potency, which 
make them .singular. 

The routine treatment of chancroids is by destructive cauterization 
with nitric or sulphuric acid. Keyes recommends a previous appli- 
cation of pure carbolic acid, in order to benumb the part and render 
the subsequent application less painful. If employed at all, the latter 
should be carefully wiped from the sore before the subsequent cauter- 
ization, as the two acids will explode if suddenly united. As the 
slough separates, the ulcer may be dressed in accordance with the 
general principles governing the treatment of simple granulating 
wounds. Vinous, carbolated, and opiated lotions, soothing powders 
of iodoform, iodol, calomel, bismuth and starch, simple unguents, and 
the interposition of a pledget of borated cotton between all affected 
and sound tissues, these in most cases suffice to insure relief. Pencil- 
lings with the nitrate of silver, though ineffective for the purposes of 
cauterization, often answer a good purpose in hastening repair. The 
prepuce may require division or circumcision. 

For the grave and extensive ulcerations, accompanied or not by 
phagedena or gangrene, there is no treatment at all comparable in 
value with the hot-water bath of an average temperature of 98° F. 
For the details of this method, the reader is referred to the paragraph 
devoted to the treatment of syphilitic chancre. 

Phimosis and paraphimosis, when complicating chancroids, require 
the surgical treatment appropriate for the relief of those conditions. 
For the accompanying adenopathy in chancroid disease, before sup- 
puration has occurred, rest is essential, with laxatives internally and 
gentle local compression. When there is great heat and tenderness, 
a few leeches may be applied. After pus has formed, it may be 
evacuated with the aspirator-needle, or by a free incision in the long 
axis of the swelling. The resulting ulcer is to be dressed and treated 
as a large chancroid. Constitutional treatment by iron, quinine, cod- 
liver oil, and the employment of a generous diet with milk, malt 
liquors, or wines, is often required in broken-down and debilitated 
patients. 

The prognosis, in uncomplicated cases, is generally favorable. The 
scar left by a suppurating gland in the groin is indelible, but becomes 
less and less conspicuous with years. Sloughing and gangrenous 
sores usually leave deforming cicatrices, especially when occurring at 
the apex of the glans, to which they are apt to give a peculiarly 
truncated shape. A just reserve should be made in all cases compli- 
cated with syphilis or extensive fistulous sinuses; the latter, as 
described above, often persisting for years. 



LEPRA. 549 

Lepra. 

Gr. AeTrpdr, scaly. 

Lepra is an infectious, parasitic disease, of exceedingly chronic course, capa- 
ble of involving all of the organs and tissues of the body, characterized by 
cutaneous pigment alterations, disordered or abolished sensation, tubercles, 
or other circumscribed or diffuse infiltrations, bullae, ulcers, cicatrices, 
atrophies, destruction of deep tissues, loss of the appendages of the skin, 
and the ultimate production of a cachexia which usually terminates fatally. 

Symptoms. — Leprosy has also been termed Elephantiasis Gr.e- 
corum, Leontiasis, and Lepra Arabum. In whatever form it 
may be ultimately manifested, its appearance is usually preceded by 
the prodromic symptoms generally recognized as the precursors of 
severe constitutional disease. These are : anorexia ; chills, alter- 
nating with mild or severe febrile attacks ; depression ; gastrointes- 
tinal disturbance ; and insomnia. Their duration is exceedingly 
variable ; in some cases, patients will remember that these or similar 
symptoms preceded for years the earliest outbreak of the disease. In 
yet others, but a few weeks' interval occurs between the prodromic 
and successive stages of the disease. It is worthy of note that the 
character of the former furnishes no clew to the severity and type of 
the latter. 

The earlier cutaneous lesions of leprosy are tubercular, macular, or 
bullous. These may be coincident or successive, or one or two of these 
types may so far predominate that another may be either altogether 
Avanting, or possess, in the general pathological history, but a trifling 
significance. It has thus been customary to make an entirely arti- 
ficial distinction between cases of leprosy, by assigning them to three 
varieties, tubercular, macular, and anaesthetic. It will be understood, 
then, in separately considering these three forms, that the distinction 
between them is useful simply for the purposes of classification ; that 
mixed cases of the disease occur which it would be difficult to assign 
to either variety exclusively ; and that each merely represents a pre- 
dominance of certain lesions at one pathological epoch. It should be 
noted also that the symptoms of leprosy are particularly remarkable 
for their polymorphism; a wide variation often existing between the 
character of two or more lesions which at any given moment are 
apparent. This is largely owing to the fact that leprosy is a general 
and constitutional disorder, the cutaneous symptoms of which are 
simply its surface markings. 

[A.] Lepra Tuberosa. 

Tubercular leprosy commonly begins in the skin with macular 
lesions. These are bean- to tomato-sized, reddish, brownish, or 
bronze-hued patches ; roundish, oval, or irregular in contour ; and 
occurring upon the face, trunk, or extremities. The skin covering 



550 



DISEASES OF THE SKIN. 



these is either smooth and shining as if oiled, or moderately infil- 
trated and elevated. 

After a period ranging in duration from weeks to years, tubercles 
rise from these maculations, varying in size from a pea to a nut, 
though they may be as large as a tomato. They are yellowish, red- 
dish-brown, or bronzed in color, often shining as if varnished or 
oiled, covered with a soft, natural, or slightly desquamating epidermis, 
roundish, or quite irregular in contour, and either isolated or grouped. 
Numbers of very small and ill-determined nodules may often be 
recognized by careful examination of the skin in the vicinity of those 
fully developed. They may be either cutaneous or subcutaneous in 
situation, and softish or quite firm to the touch. 

Fig. GO. 




Lepra tuberculosa. (After Dan 



Boel-k.) 



The site of predilection of leprous tubercles is the face ; and their 
massing in great numbers upon this region produces the characteristic 
deformity of the countenance which has given to the disease one of 
its names, Leontiasis (face of a lion). In such faces the tubercles 
are ranged in parallel series above the brows, down the nose, over 
the cheeks, the lips, and the chin. In consequence of the infiltration 
and development of the lesions, the brows deeply overhang the globes 
of the eyes, the lids become affected with a partial ptosis, the lips 
pout, and the ears are so studded with tubercular masses as to project 
from the side of the head. The trunk and extremities, including the 
palmar and plantar surfaces, are then usually to a less degree 
involved. Occasionally, indeed, with extensive development of 
tubercles upon the face and ears, there may not be more than from 
five to fifty upon the rest of the body, and these either widely 



LEPRA. 



551 



dispersed and isolated, or agglomerated in a single, hard, flat, elevated 
plaque of infiltration upon the elbow or thigh. 

With these cutaneous lesions there is often involvement of the 
mucous surfaces, especially the velum palati and larynx. In the 
case of a leper affected with the tubercular form of the disease whom 
the author exhibited at the clinic in 1879, 1 there was very marked 
gruffness and hoarseness of the voice, and the larynx and velum were 
studded with pin-head to pea-sized, ashen-hued tubercles. Others 
may form upon the conjunctiva and the Schneiderian membrane. 

Fig. 70. 




Tubercular leprosy (from a photograph of a leper in tlie Sandwich Islands). 

These tubercles may degenerate into ulcers ; or undergo resorption 
and disappear, leaving in their place pigmented atrophic depressions ; 
or lose their shape in consequence of partial resorption. I have thus 
seen a large plaque flatten centrally till an annular disk was left to 
indicate its former site. 

It should be borne in mind, however, that the course of the disease 
is exceedingly slow, and that years may elapse before these several 



1 Chicago Med. Journ. and Exam., December, 1879, 
larynx. 



ith cut showing laryngoscDpic appearance of 



552 DISEASES OF THE SKIN. 

changes are accomplished. The disease, indeed, often appears to be 
quiescenl for months at a time, after which with the occurrence of 
fever acute; or subacute manifestations appear, and a relatively rapid 
progress is made toward its fatal conclusion. Long before the latter 
is reached there are usually, in tubercular leprosy, intermingled symp- 
toms of anaesthetic type, such as the occurrence of bullae or of anaes- 
thetic patches with and without pigmentation. Toward the last, the 
mutilations effected by the disease may result (Lepra Mutilans). 
Phalanges of the fingers or toes, whole digits, an entire hand or foot- 
may then become partially or wholly detached by ulcerative, atrophic, 
or other degenerations of skin, bones, and ligaments, hastened or not 
by intercurrent attacks of lymphangitis, erysipelas, septicaemia, and 
irritative fever. 

The stadium of this type of the disease may extend through ten 
or even more years. After its full development, the peculiarly 
dejected countenance of the leper with his leonine facies and general 
appearance of cachexia, are highly characteristic. 

[B,] Lepra Maculosa. 

This form of the disease is chiefly distinguished, as its name implies, 
by its macular lesions. These have the general character of those 
described as preceding the appearance of the leprous tubercles. They 
are diffused or circumscribed, roundish or irregularly shaped, and in 
color yellowish, brownish or bronzed, often shining or glazed. They 
may be infiltrated or not; and in the former case, be slightly raised 
from, or on a level with, the adjacent tissues. At times, they appear 
as lardaceous deposits in the skin, whitish, reddish, or even blackish 
in color, with a telangiectasic border. These patches are usually at 
first hyperaesthetic, but finally become quite insensitive, so that a 
lancet can be thrust deeply into them without producing the slighest 
sensation. 

The pigment variations in macular lepra are noticeable. At times, 
a distinctly anaesthetic patch may be readily limited both by its lack 
of sensation and of normal color ; at others, either symptom may 
fail to correspond with the area of involvement defined by the other. 
Thus a palm to platter-sized, texturally unaltered area over the thigh 
or belly, may suggest a vitiligo by its relatively slight pigmentation 
and its distinct contour, beyoud which are sepia- to deep-chocolate 
tints, gradually fading toward some adjacent and similarly involved 
patch. Yet this area Mill often differ materially from that of vitiligo 
in other respects. Every inch of the former may be totally insensi- 
tive to the prick of the lancet, and be moreover of a dull, tawny, 
yellowish, or parchment-like hue, never having the peculiar milky- 
white tinge of vitiligo. Again, this anaesthesia may extend widely 
beyoud the line traced by the pigment anomaly, or even within the 
latter vary, islets of skin capable of perceiving sensation, being in 
cases here and there discernible. 



553 



f C] Lepra Anaesthetica. 



This variety may be, as has been described, commingled in its 
symptoms with each of the others. With and without these, how- 
ever, there is commonly noted first an eruption of bullae, bean- to large 
nut-sized, with a roof-wall constituted of the entire thickness of the 
epidermis, filled with a clear tinted or blood-mixed serum, occurring 
usually upon the extremities. The cicatrices which follow these are 
atrophic patches, often far greater in extent than the base of the 
original bulla; whitish, shining, glazed, or better described as of a 
tint suggesting the hue of mica ; circular in outline, forming also the 
dumb-bell figure by coalescence or juxtaposition. These are always 
anaesthetic; and may coexist with macular and anaesthetic patches 
upon the trunk or other portions of the body. Neither those of the 
one class nor of the other, are, however, disposed over the surface of 
the body in lines, bands, or curves corresponding to the distribution 

Fig. 71. 




Anaesthetic leprosy with mutilating results (from a photograph taken < 
Sandwich Islands). 



leper in the 



of the cutaneous nerves. The greatest irregularity is displayed ; 
asymmetry is the rule. Occasionally, however, the ulnar and other 
nerves accessible to the touch, are recognized to be tumid, tender, 
insensitive, or as rigid as indurated cords. General atrophic cuta- 
neous symptoms follow these ; the skin becomes dry and harsh ; there 
is manifestly little or no sebaceous product; the sweat is scanty; the 



554 DISEASES OF THE SKIN. 

muscles atrophy; the hairs fall; the lymphatic ganglia enlarge; the 
skin of the face seems tightly stretched over the bones. As a result 
of deforming atrophy of the lids, .epiphora and consequent orbicular 
changes ensue, and the parted lips permit constant escape of saliva. 
The fingers are half drawn into the palm of the hand; the nails are 
distorted, and, later, ulceration occurs. The ulcers are irregular, oval, 
roundish, linear; covered with thin, blackish, flattened, tenacious, 
never rupioid, crusts; their bases are soft, their floors covered with a 
pultaceous debris often mixed with blood; the whole often insensitive 
to every foreign body and external application. Lastly the symp- 
toms of lepra mutilans often occur, digits, or portions of the carpus, 
metacarpus, or corresponding parts of the foot being detached from 
the body. 

Death may ensue at any time during the course of the disease from 
septicaemia, exhaustion, or any of the intercurrent affections to which 
a patient in such condition is particularly disposed. Thus a leper 
was lately accidentally choked to death in San Francisco by some 
perversion of the function of deglutition. The disease, however, in 
this form is said to last from eighteen to twenty years, and is thus 
less rapidly fatal than the tubercular variety. 

Etiology. — Leprosy is a contagious and infectious parasitic disorder 
produced by the bacillus lepra?. Secretions of a leprous patient con- 
taining these bacilli or their spores, are 
Fig. ?2. the usual vehicles by which the disease is 

transmitted from man to man. The ques- 
tion of the inheritance of leprosy may be 
regarded to-day as in much the same posi- 
tion as that relating to the inheritance of 
tuberculosis, an admitted fact as yet not 
fully explained. Men are more often 
affected with the disease than women. The 
disease is more common after the second 
decade, though children are occasionally 

Larynx of patient affected with f d j fa victimg# 

lepra tuberculosa. (The author's „. i • 1 t m • r> 1 

case .) 1 he geographical distribution of leprosy 

is widely extended. In countries where 
it has previously existed, its appearance is invariably due to the con- 
tagion of sound individuals by lepers infected in a country where the 
disease is prevalent. Neisser formulates the law of its prevalence by 
stating that the number of lepers in any country bears an inverse ratio 
to the laws executed for the care and isolation of infected persons. 

The disease exists in the interior and throughout the seaboard regions 
of Africa, including Egypt; in Arabia, Syria, Persia, China, Japan, 
and India; in the Islands of the Mediterranean, Black, Caspian, 
and China Seas, of the Indian Ocean, and of the Australian Archi- 
pelago; in Norway and Sweden, Iceland, Russia, Turkey in Europe, 
Spain, France, Portugal, Greece, Italy, and sporadically in Germany, 
England, and the smaller European States; in Northern, Central, 




LEPRA. 



555 



and South America, and the West India Islands. In our own 
country, special attention has been directed to the subject by the 
existence of the disease in an epidemic form in the Sandwich Islands, 
with which the Pacific States sustain close commercial relations; by 

Fig. 73. Fig. 74. 



^ 





Larynges of lepers affected with lepra tuberculosa. (Elsberg's 



its occurrence among the Chinese immigrants in San Francisco and 
other portions of California; by cases reported from New Orleans 
by Burns, 1 Bemiss, 2 Jones, 3 and Solomon, 4 and by various reports of 
sporadic cases observed in Minnesota, Maryland, Illinois, Nebraska, 
New York, and other States of the Union, by Gronvold, Hoegh, 
Bendeke, Rohe, Piffard, Elsberg, Atkinson, the author, and others, 
collected by the Committee on Statistics of the American Dermato- 
logical Association, and presented to that and other bodies in special 
papers. Drs. White and Graham, of the same committee, have also 
contributed to the history of the colony of lepers which has long 
existed in Tracadie, in the province of New Brunswick. 

With this wide geographical distribution, it is yet clear that the 
disease exists endemically in certain countries, and also in certain 
regions of the same country, with greater frequency than in others. 
All attempts, however, to connect its origin with malaria, with a 
residence near inundated sea marshes, with the ingestion of a diet 
consisting largely of fish, or of a diet from which salt has been 
largely excluded, have failed of any recognized success. It is true 
that probably the larger number of all living lepers are those who 
have been poorly fed, and otherwise subjected to the most insalubrious 
of influences, but the disease also attacks, though far more rarely, 
persons whose social position and hygienic surroundings are of the 
best. It occurs in both sexes and at all ages ; and, despite all efforts 
to show the contrary, bears no relation to syphilis. Lepers become, 
however, syphilitic if infected with the disease, precisely as they may 
and do acquire variola, varicella, morbilli, erysipelas, and phthisis. 
The Hebrew Scriptures, are often interpreted as showing that the 
disease among the Jews in Palestine was regarded by them as con- 
tagious and so treated. The modern student of these writings will, 
however, be convinced that this interpretation is erroneous. The 



1 Arch, of Med., December, 
3 Ibid., March, 1878. 



2 N. 0. Med. and Surg Journ , April, 1 
4 Trans. Louis. State Med. Assoc, 1879. 



55G DISEASES OF THE SKIX. 

leprosy of the book of Leviticus not only includes lepra, as that term 

i- andersl 1 to-day, but also psoriasis, scabies, and other cutaneous 

affections. The leper in the eye of the Mosaic law, was ceremonially 
unclean, and capable of ooramunicating only a ceremonial unclean- 
ness. Several of the narratives contained in these books bear witness 
to the fact that the Oriental leper was occasionally seen doing service 
in the court of kings, and even in personal communication and con- 
tact with officers oihigh rank. 

Pathology, — The histological element of leprosy is represented by 
a new growth of round, oval, uni- or bipolar or otherwise irregularly 
contoured bodies. These originate either in the connective tissue of 
the skin, mucous membranes, adventitia of the vessels, or nerve- 
sheaths, or are derived, as Schmidt has shown, from the epithelium, 
endothelium, aud even the fat elements of the affected tissue. These 
are siugle, or grouped in a collection of two, a dozen, or even more 
individuals : such groups being arranged in elongated, oval, pyram- 
idal, or ellipsoidal forms. Making its earliest appearance in the 

Fig. 75. 



S S 




I 



s 

I 



Bacilli of leprosy, a, epithelial scale About X 1200. (From one of the author's patients.) 

reticular portions of the corium, the growth may progress thence 
externally toward the papillary layer and epidermis, or downward 
to the subcutaneous tissue, or develop in both directions simulta- 
neously. Gradually there is invasion of the pilary and sebaceous 
follicles, the coil -glands being apparently less frequently involved. 
In the same way, the fat and vascular elements undergo a transfor- 
mation into the newly formed elements. The viscera are also 
changed by the pathological process, particularly the liver, kidneys, 
and spleen. By degeneration of these elements, atrophy, ulceration, 
and eventually the mutilating deformities of the advanced stages of 
the disease are induced. 

The result of the researches of Schmidt are in accord with the 
observations of Virchow, relative to the peculiar changes in the 



LEPRA. 557 

nerves. Explaining thus the hypersesthetic, anaesthetic, and possibly 
also the pigment alterations so characteristic of the malady, prolifer- 
ating elements are recognized by this author in the ependyma of the 
central canal of the spinal medulla, in the posterior commissure, and 
about the fourth ventricle. The nerve-fibres in the posterior and 
other white columns, undergo degeneration, as also those of the 
medulla oblongata, the corpus striatum, and the Gasserian ganglion, 
the latter being in one case small, indurated, and its connective 
tissue sheath thickened and adherent to the dura mater. The sheaths 
of the larger nervous trunks have been also seen to be involved, and 
the peri- and endo-neurium atrophied as a result of previous infiltra- 
tion, the axis-cylinders often, however, persistent. 

The relatively slow progress of the disease is explained by the 
exceedingly slow development of the new formed material ; its inapti- 
tude, for long periods of time, to undergo retrogressive metamorphosis; 
and its tendency, for similar periods, to invade the skin exclusively, 
thus spariug for years the viscera whose ultimate involvement neces- 
sitates cachexia and a fatal issue. 

In leprosy, as in scrofuloderma and syphilis, the aggregation of 
the cellular elements in the new growth tends to form cutaneous and 
subcutaneous nodes. Similar nodules are found in cornea, cartilage, 
testicle, spleen, liver, bone, and other affected organs. The body of 
each cell sometimes grows till it has four and five times the dimen- 
sions it originally possessed ; being surrounded in its full maturity 
by an abundant vascular plexus. 

The specific parasite of leprosy, the bacillus lepras, is discovered 
in no other disease affecting man. It is visible within all cells 
actively concerned in the leprous new formation. They are delicate 
rods, with tapering extremities, one-half to three-fourths the diameter 
of a red blood-corpuscle, and have a breadth about one-fourth of their 
length, as distinguished from the bacillus of tuberculosis. Granular 
particles are occasionally recognized sprinkled through the protoplasm 
of a single cell which Neisser supposes to be either products of degen- 
eration or spore formations. These various microorganisms have 
been chiefly studied and described by Hansen (1870, 1874, 1880), 
Carter (1875), Neisser (1879), Cornil (1881), Hillairet and Gauche 
(1881), and in our country by Hermann, of Baltimore. These ob- 
servers not only recognized parasitic organisms in various tissues of 
the bodies of patients living and dead of leprosy ; but have shown 
that the bacteria thus discovered, were the causes of the disease. 

It is true that no human being has ever been infected with leprosy 
by the medium of culture-fluids originally derived from an infected 
person ; but the demonstration to that point is satisfactorily conclu- 
sive. The appended illustration represents the bacillus lepras recog- 
nized in the nodules taken from the arm of a patient affected with 
tubercular leprosy, exhibited at the author's clinic in 1886. 

These organisms have since been recognized in mucous membranes, 
perichondrium, cartilage, testicle, liver, spleen, kidney, lymphatic 
glands, and in the large cells between the peripheral nerve-fibres and 



558 DISEASES OF THE SKIX. 

fasciculi. Neisser has failed to recognize them in the spinal cord, 
muscles, pemphigoid lesions (bullae), and rete mucosum. The older 
and larger the cells, the more numerous and more closely packed are 
the rods of bacteria contained within them. 

Diagnosis. — In well-marked eases the recognition of leprosy is 
simple. In its prodromic periods, no suspicion of its existence would 
be awakened in countries where the disease was not endemic. 

From syphilis, which is also a disease whose lesions are polymor- 
phic in character, lepra can be distinguished by its much greater 
chronicity ; its larger and brownish-yellow, glazed tubercles ; its 
frequenl hyperaesthetic and anaesthetic symptoms ; its bullous lesions, 
rare in acquired syphilis ; the far more extended areas of its erythem- 
atous macules; its blackish crusts, lacking the rupioid aspect of 
those in syphilis; its leathery, mica-tinted cicatrices; and the charac- 
teristic leonine facies of its tubercular forms. 

Morphcea and vitiligo are both unattended by constitutional changes, 
and more particularly by hyperaesthetic or anaesthetic symptoms in 
the affected patches. The atrophic and often deeply pigmented con- 
dition of the skin in the final stages of pityriasis rubra, associated 
with the emaciation and febrile condition of the patient, might mis- 
lead for a time the observer who had not a full history of the case. 
Multiple sarcomata, especially upon the face, are followed by much 
more rapid degeneration and a fatal result. 

Finally, we are now in position to assert boldly that, certainly in 
America, the diagnosis of leprosy requires not only clinical symptoms 
but a definite contagion. Whether the history of such transmission 
from one individual to another be or be not obtainable, it is certain 
that no person ever manifests leprous symptoms who has not been 
infected by some other individual who is the victim of the disease. 

Treatment. — One of the most important considerations relative to the 
therapy of leprosy is that requiring the segregation and isolation of 
all lepers from contact with the uninfected. In some countries, those 
particularly where leprosy prevails, wholesome laws enforce this 
separation of the infected, and charitably provide also for the care of 
the wretched victims of the disease. In this country, where leprosy, 
in consequence of its great rarity, has not yet awakened the attention 
of legislators beyond the point of forbidding the importation of 
infected persons, the proper care of lepers in a community only too 
ready to take alarm even at the name of the disease is a serious 
matter. Many of our public hospitals for the care of the sick poor 
refuse to receive them. The author has had experience in several 
States of the Northwest, where the officers of health-boards were 
powerless to make proper provision for the care of a leper whose case 
was brought to their attention. 

No remedies are known to have a directly curative effect in leprosy. 
As a consequence, the treatment of the disease is that suggested to the 
intelligent practitioner by the indications in each case. The most 
important of the latter is, when the patient happens to reside in a 



LEPRA. 559 

district where the disease prevails, an immediate change of residence 
and climate ; the adoption of a highly nutritious diet ; and the exhib- 
ition of roborant remedies, including steel, quinine, cod-liver oil, and 
often the moderate use of wines and malt liquors. Mercury, arsenic, 
the iodine compounds, Hoang-Nan in pills of three grains (0.266) ; 
creasote, in half-drop doses (0.033) ; the oil of cashew nut, gurjun 
balsam, ichthyol, and chaulmoogra oil, internally and externally, have 
all been employed with varying success by different practitioners, but 
an unprejudiced review of the maximum of results thus obtained, will 
establish the conviction that no one of the remedies named may be 
regarded as in any sense possessing a controlling influence over the 
disease. Most of them have been employed by skilful physicians, 
sufficiently wise to enforce simultaneously the most generous tonic 
regimen, thus clouding with some doubt a belief in the part played 
by the medicament in the production of the result. In the case of a 
leper and his little daughter in the State of Nebraska, who were 
treated by the author for some time with chaulmoogra oil, very 
marked benefit was noticeable in the course of a few months, a result 
he is quite willing to credit, in this instance, to the salubrious sur- 
roundings of a farm in the country. 

Every secreting ulcer and open surface in the person of a leper 
requires prompt and absolute disinfection with a solution of bichloride 
of mercury, in order to destroy the bacilli that are commonly con- 
tained in it. 

Baths are of great value in all these cases, and may be medicated 
with any desirable substance. It should not be forgotten in the local 
treatment of leprous tubercles, ulcers, and other lesions, that however 
foreign the disease maybe to this climate and this country, the simple 
principles, dermatological and surgical, by which one is governed in 
ordinary cases, are here not to be forgotten. Disinfectants, carbolic 
acid, bland unguents, inunctions, and local stimulants of the skin, are 
as useful, when properly applied to the leper, as to the syphilitic, the 
cancerous, and the scorbutic. 

Prognosis. — The future of the leper is indeed dark. The disease 
is malignant in character, and, however protracted, a fatal result is 
usually inevitable. Still, with a change of climate and improved 
hygienic conditions, much can be accomplished. There can be no 
question that the Scandinavian lepers who have removed to this 
country have been greatly benefited by the change. Such, indeed, 
was the opinion of the late eminent Professor Boeck, who, during 
his useful career, visited Minnesota, and there studied the history of 
eighteen leprous immigrants who had come from his own country. 
He believed, in fact, that the change in some cases would work a 
complete arrest of the disease. A careful study of the history of 
leprosy in America will induce the belief that such a favorable result 
can be anticipated after residence in the Northwestern States, as well 
as in other portions of this country. . 



5fi0 DISEASES OF THE SKIN. 



Pellagra. 

Lat. pellis, the skin ; eager, diseased. 

This disease has attracted attention by its extensive ravages in 
Lombardy and the contiguous provinces, including a portion of 
Southern France and Spain. It is also termed Risipola Lombarda 
(Lombardy erysipelas), Lombardy Leprosy, and among the common 
people, La Rosa. It is a constitutional endemic disorder, accom- 
panied by an exanthem, which justifies its brief consideration in this 
connection. 

The first symptoms of the disease are prodromic, and characterized 
by marked fatigue, malaise, and occasionally by febrile symptoms. 
Soon the face, neck, chest, and backs of the hands and forearms 
(when exposed to the sun) are affected with an erythema of a dull, 
lurid huej which may be accompanied by desquamation, occurring in 
successive years, chiefly in the summer season, often fading, at times 
with desquamation, in the autumn. After frequent relapses, the skin 
becomes of a dark olive- brown, bluish-red, or deeply pigmented and 
bronzed hue, and general exfoliation of the epidermis follows in large 
flakes. Simultaneously, an extraordinary degree of muscular feeble- 
ness is noticed ; the skin becomes pruritic or hyperaesthetic ; and a 
sensation of chilliness is induced, similar to that observed in general 
exfoliative dermatitis. As in that disease also, the fingers gradually 
become semi-flexed into the palm, and gastro-intestinal derangements 
supervene, accompanied by a furred tongue, inappetence, colicky 
pains, and diarrhoea. Disorders of the nervous system are betrayed 
by melancholia, disturbed vision, idiocy, convulsions, and symptoms 
of meningitis. Post-mortem, pachy-meningitis, with induration, 
atrophy, and other secondary changes of the brain and cord, have 
been observed. 

Pellagra has been very generally believed to originate in the use, 
as an article of diet, of maize which was either invaded by the fungus 
of ergot, or had developed other deleterious substance after its reduc- 
tion to a coarse powder. While this cannot be said to have been 
fully disproved, it is certain that individuals have suffered from the 
disease who have never partaken of maize, and also those who have 
not been specially exposed to the action of the sun, which in some 
cases seems to have served as the exciting cause of the disease. The 
exact etiology of the malady should rather be traced by the statesman 
and poljtico-economist. The wretchedness, poverty, poor food, and 
hopeless moral and social condition of the inhabitants of the pella- 
grous districts, many of them toiliug under a burning sun, half- 
starved, emaciated, and despairing, should explain largely the symp- 
toms of the scourge which afflicts them. Certainly there is here to 
be found a very satisfactory explanation of the failure of several 
writers on the subject to describe a disease of such typical aspect and 
career as to command recognition of its distinct and special identity. 
Subjected to the influences named above, a large population could 



CAKCINOMA. 561 

scarcely fail to exhibit a wide range of differences in the symptoms 
by which was expressed their physical protest against the severe 
ordeal to which they were alike exposed. 

The treatment is that manifestly indicated in the facts set forth 
above. 

Actinomycosis. [Ray-Fungus.] 

This is a disease originally recognized in the jaws of horned cattle 
by Bollinger ; and shown by Israel, Ponfick, Johne, and others to 
be occasionally transmitted to man. The disease is said, in such 
cases, to gain access to the jaw by the avenue of the cavities in carious 
teeth, where the fungus lodges and fructifies. One or several small 
or large tumors form in the jaw and submaxillary region, after the 
fungus has fully developed, in consequence of the formation of granu- 
lation tissue. By a process of ulceration and sloughing, the tongue, 
pharynx, larynx, and other parts may be invaded ; and in cases even 
the intestinal canal, lungs, and spleen. The nodules which form and 
which once were believed to be sarcomatous, contain a fungus seen in 
the form of millet-seed sized and smaller yellow masses mingled with 
the new-formed granulation tissue. The fungus by its growth only 
seems to excite the chronic inflammatory process in the tissue without 
directly influencing the cells of which it is built up. Its title of 
ray-fungus is derived from a characteristic radiation of the. grouped 
filaments of the vegetation. As degeneration progresses in the deeper 
parts attacked by the fungus (bone, periosteum, etc.), fistulous tracts 
communicate with the skin and furnish a secretion in which the para- 
site may be recognized. 

The diagnosis rests upon the discovery of the small, yellow granules 
in which the fungus may be detected. The disease is not to be con- 
founded with extra-periosteal abscess of the soft tissue about the jaw 
due to carious teeth. 

The treatment, after thorough employment of antiseptics and para- 
siticides, is largely surgical. 

Carcinoma. 

Gr. KapKivog, cancer. 

Carcinoma of the skin, is a term employed in the designation of the several 
forms of malignant tumors which are in part constituted of epithelial new 
growth, either occurring primarily in the cutaneous tissues, or appearing 
there after the involvement of other organs. 

The term Cancer has been both loosely and definitely employed in 
the designation of malignant cutaneous tumors. Every cancer of the 
skin is, according to Heitzmann, necessarily both alveolar and epithe- 
liomatous in structure ; while Kaposi distinctly recognizes forms of 
cancer which are not epithelial. In these pages, for the sake of 
retaining a convenient clinical distinction, the term carcinoma, or 
cancer, is used generically to include epithelial, fibrous, and melanotic 



562 DISEASES OF THE SKIN. 

neoplasms. It will be understood, however, that in the structure of 
all iif these new-formed groups epithelium plays an important part. 

Epithelioma. (Epithelial Cancer.) 

Three varieties of epithelioma are recognized — the superficial, the 
deep, and the papillary. 

Superficial Epithelioma is usually first displayed upon the 
sound skin in the form of one or several, pin-head sized papules, flat 
infiltrations, or nodosities of a dull-yellowish, reddish, grayish, or 
dirty wax-like hue. The growth may also have its origin in pre- 
viously existing lesions of the skin, which are both numerous and 
different from each other. Among the latter may be named fissures 
and excoriations (especially those long teased by caustic applications), 
warts, naevij acneifbrm and molluscoid lesions ; and the dry or 
greasy epidermal scales often seen at the orifices of the sebaceous 
glands in the faces of the aged. The outline of the newly developed 
growth as a consequence varies, being roundish, linear, or irregular. 
As a result of accident or traumatism (especially scratching and 
picking, which the history of a large proportion of all cases includes),, 
a superficial excoriation forms, which may be covered with a sero- 
sanguineous crust, after the desiccation of its scanty and ichorous secre- 
tion. In the progress of its development, it is often noticed that new 
foci of disease appear in the immediate vicinity of the first, repre- 
sented by sub-epidermic, indurated nodules, or superficial "pearls" 
resembling milia, whitish and lustrous, with marked tendency to 
vascularization, exfoliation, and superficial ulceration. 

The result is the ultimate formation of an ulcer, called also the 
Rodent Ulcer, whose characteristics are marked. These are a 
roundish, fissured, or slightly angular contour; and a reddish or 
reddish-brown, irregular, granulating, and mamillated floor, covered 
with a thin, translucent, viscid serum, which, in drying, suggests 
the effect of a varnish over the part. The edges of the ulcer are 
clean-cut, indurated, usually well attached ; and, seen in horizontal 
profile, irregularly indented. The symptoms are slight at first ; the 
lymphatic ganglia and general health being unimpaired. Its site of 
election is the face, particularly the eyelids, nose, temples, and lips, 
though the genitalia, hands, and feet may be affected. Of two 
hundred and fifty eases collated by Heurtaux, in one hundred and 
ninety the face was attacked. 

The subsequent course of the lesion varies, its evolution being 
generally slow and accomplished in years. Sometimes having 
attained a maximum of size, an ulcer, if unmolested, long persists 
without appreciable change. In other cases, the base cicatrizes and 
the epithelioma completely exfoliates, leaving an outlying linear 
ulceration which may persist or spread. In vet other cases, after a 
persistence of ten to twenty years, the ulcer may spontaneously close 
and the disease be at an end. Finally, any one of the destructive 



CARCINOMA. 563 

and malignant cancerous processes may be awakened, and the epi- 
thelioma be thus transformed from the type of the superficial to that 
of the deep variety of the disea.se. 

Deep or Tubercular Epithelioma. — This variety may origi- 
nate in the manner already described, or may be from the first 
characterized by its specific features. It commonly begins by the 
formation of roundish, very firm pea-sized nodosities closely set 
together, deeply in the skin and subcutaneous connective tissue, or 
thus situated and well projected from the surface. In the course of 
months and years these develop to form a nut- or even small egg- 
sized tumor, roundish, dark recldish in color, and delicately vascular 
on its surface. This may be a deep flattish or globoid development 
within the skin ; or a well-defined tumor attached to it ; or (and this 
is a common form) a dense, thick, flattened plaque, one inch or more 
in diameter ; its walls steeply descending to the sound skin on either 
hand or moderately everted ; its centre depressed by atrophic changes ; 
its surface shining, waxy, pinkish or red, with ramifying capillaries. 
"Satellites" may form in its vicinity. 

Degeneration of these forms produces in the course of time an 
ulcer either quite like that described above, or one which deeply and 
destructively encroaches upon the tissues beneath. In advanced cases, 
the latter is irregular in contour, with a clean-cut, everted, indurated 
lip ; eroded and " gouged," hemorrhagic and granulating floor; thin, 
viscid secretion which is purulent at times when the resulting destruc- 
tion is rapidly accomplished ; and a deep attached base which may 
be perforated by a crateriform excoriation extending down to or 
through muscles, fascia?, cartilage, and bone. The lymphatic ganglia 
become simultaneously involved, and a general cachectic condition 
fully established. Death may ensue from marasmus, exhaustion, or 
haemorrhage, in the course of several months or from one to three 
years. 

Papillary Epithelioma. — The cancer in this variety assumes 
the form of a malignant papilloma. In these cases, a pedunculated 
or sessile, narrow or broad based, smooth-capped, or spongy and 
verrucous vegetation is attached to the skin upon which it forms. 
It may be originally as small as a pea, but usually increases consider- 
ably in volume, being not rarely pigeon's and turkey's egg-sized. 
The surface is either dry, reddish-yellow, smooth, and lustrous ; 
exfoliating, and secreting an offensively smelling sanguineous or 
translucent fluid ; or moist, granulating, filamentous, and intermingled 
with hairs, as when it occurs upon the bearded cheek. Degeneration 
occurs later, fissures forming first ; subsequently appear superficial, 
and finally deep, ulcers which ultimately assume all the features of 
those described above. 

Singular varieties of papillary epithelioma are occasionally seen 
upon the face. In a case lately observed by the author, the entire 
face of an elderly man was covered with rings having a diameter of 



561 DISEASES OF THE SKIN. 

an inch or more, of which the centre was largely composed of densely 
indurated, cicatricial tissue. The borders of these rings were built 
up of a reddish-brown, warty, cancerous growth, secreting slightly, 
here and there commingled with the hairs of the face (beard, eye- 
lashes, brows), and elevated one-fourth of an inch and more above 
the general level of the integument. Growths of this sort are not 
rarely seen upon the back of the hand, over the forearm, and on the 
leg. Distinctly circinate forms arc produced, the vegetation here 
having a dryish appearance, a brownish-red crust, neither bulky nor 
uniform, a cicatriform'or infiltrated central area, and an exceedingly 
slow course. In some cases the epithelioma forms a soft, hemispherical, 
small-nut to egg-sized tumor, which, upon pressure, discharges 
numerous convoluted plugs, composed of epithelium, fatty masses, 
and a puruleut secretion. The bases of these soft masses are remark- 
able for the ease with which they can be curetted, and thus radically 
removed. 

These varieties or types of epithelioma may coexist in different 
portions of the same integument ; or the one may develop from the 
other, a malignant papillary growth springing from a superficial or 
deep cancerous infiltration. Familiar examples of the disease are 
seen upon the lids and contiguous portions of the nose ; the cheek and 
the lower lid, the latter being often drawn iuto ectropion by a cicatri- 
form bridle or band ; the nose or lip and adjacent mucous or osseous 
tissue ; and the glans and prepuce where the vegetating forms are of 
more frequent occurrence. The vast destruction wrought by the 
widest development and consequent degeneration of epithelioma is 
sufficiently recorded in the annals of both medicine and surgery. 
The author was lately consulted in the case of a woman sixty-four 
years of age, in the centre of whose face an ulcerating epithelioma had 
left a wide chasm, after destroying three-fourths of the nose and upper 
lip, and the hard palate with all the upper teeth and the antrum. 
The bones at the base of the skull were exposed. The case illustrated 
well the occasional remarkable tolerance by the system of the pro- 
foundest encroachments of epithelioma. She was then digesting and 
assimilating food with fair profit, and suffered chiefly from paiu. She 
did not die till several months had elapsed, and then only as the result 
of hemorrhage from an ulcerative opening into one of the large arteries. 

Cancer of the Head. — In this region of the body nearly three- 
fourths of all cancers of the skin are recognized. Upon the brow, 
alse of the nose, temples, cheeks, chin, scalp, or other part, the 
disease may begin either upon or beneath entirely normal skin, or in 
that which has been pathologically changed. The origin of the 
disease is usually ascribed to the picking, scratching, or shaving of 
a sebaceous wart in the old man ; or in similar traumatisms of acnei- 
form, seborrheic, or furuncular lesions in either sex. In other cases, 
the dermatologist, consulted with reference to some other ailment of 
the skin, can recognize, in persons of the age most liable to such acci- 
dents, one or several pin-head-sized, or larger milium-like nodules, 



CARCINOMA. 565 

clustered about the temples or nose, which indicate the site of the 
awakened epitheliomatous change. The disease progresses very 
slowly, spreading superficially, along the alse of the nose in irregular 
lines, in more complete centrifugal outline over the temple and brow ; 
almost symmetrically over the tip of the nose, and with odd indenta- 
tions of coutour in the dense integument immediately in front of the 
tragus of the ear. The vegetating forms are more common on the 
brow, scalp, and chin; the "rodent ulcer" type, over the temples 
and cheeks. The more superficial varieties in any part of the face 
may be slowly converted into the deeper. The flattened, egg-sized 
disks of infiltration are more common on the cheeks and chin. 

The devastation produced by malignant cancer is nowhere more 
conspicuous than in the face. Cartilage, bone, muscle, and entire 
organs melt before its ravages with astounding readiness. During 
the last two years, the author has seen a circumscribed flat epitheli- 
omatous infiltration, limited for years to one cheek, spread to the 
point of destroying the ear, eye, and inferior maxilla of one side of 
the face, opening into the larynx and oesophagus, and not producing 
fatal results till the jugular vein of the same side had been opened by 
ulceration. 

Cancer of the Lower Lip, far more common in men than in 
women on account of the tobacco habits of the former, may arise 
either as a minute nodule, or circumscribed thickening on or near the 
vermilion border, usually of one side , or as a linear, narrow, and 
shallow excoriation, often protected by a thin crust, extending well 
along the mucous edge of the lower lip that is in contact with the 
other when the two are lightly approximated. Later, the lip may be 
the seat of a defined tumor, small-nut to egg-sized, which may deeply 
involve the entire thickness of the lip, encroach upon the chin, loosen 
the teeth, destroy the gums, larynx, pharynx, tongue, and maxilla; 
and eventually produce one of the most formidable and remediless 
chasms of the lower part of the face already described. 

Cancer of the Genital Organs is submitted to the surgeon 
far more frequently than to the dermatologist. The glans penis and 
prepuce are occasionally the seat of the warty variety; but the 
scrotum, labia," thighs, mons veneris, and abdominal walls, as well as 
the parts first named, may be involved in the superficial or deep form 
of cancer. In persons of cleanly habits, the superficial variety of 
epithelioma may remain in this region as indolent and innocuous as 
upon the face. But where filth is permitted to accumulate about the 
part (lochial, menstrual, catarrhal secretions, pus, urine, feces, etc.) 
the spread may be relatively rapid. In such cases the ulcer is deep, 
seated upon an indurated and very tender base, and has the steep, 
punched edge and hemorrhagic floor of the rodent ulcer. Ulceration 
may, later, open the rectum, vagina, corpora cavernosa, perineum, 
and deep perineal fascia, resulting in vast destruction that proves fatal 
by exhaustion of the forces of the aged patient. 



56(3 DISEASES OF THE SKIN. 

Cancer of the Extremities, particularly of the back of the 
hand, is at first usually of the papillomatous, or flat, superficial form. 
It may first appear upou the left hand of right-handed patients. Its 
progress is indolent, and when properly treated is much less liable to 
grave ulceration, than epithelioma^ in different situations. In other 
cases, especially on the lower extremity where the force of gravity 
generally aggravate- any ulcerative process, caries, necrosis, fistulse, 
loss of phlanges, etc., may result. 

Paget's Disease of the Nipple, first described by that author 
iu 1874, 1 is a disease of women from forty to sixty years of age, 
affecting the nipple and areola. An intensely red, raw, granulating 
surface begins by exuding a copious, clear, viscid secretion, accom- 
panied by sensations of intense pruritus, heat, and bflrning. This is 
followed by unmistakable signs of epithelioma iu one or another of 
the forms described above. Thin believes that the cancerous change 
involves the mouths of the lactiferous ducts, which spreads thence to 
the nipple, skin, aud deep mammary structure. Munro, Anderson, 
Sherwell, Duhring, and others have reported eases of this kind, 
which Schwimmer conclude- present no peculiarities entitling them 
to separate classification. 

EHolof/y. — The essential causes of cancer are unknown, though 
there can be no question that mechanical, chemical, and other local 
irritations are often the immediate excitants of its pathological 
processes in the predisposed skin. In this way the excoriations, 
warts, naevij and other lesions named above, though not in them- 
selves cancerous, may become the original sites of the disease. In this 
way, too, the irritation produced upon the lip of the smoker by his 
pipe or tobacco; the local disorder about the inner canthus of the 
eye resulting from occlusion of the lachrymal ducts; the frequent 
teasing by caustic or other substances, of the wart on an old man's 
hand; and other agencies disturbing the balance between waste and 
repair, aided at times by senile atrophic changes, may result in the 
development of an epithelioma. The possibility of the transmission 
of cancer by heredity has almost ceased to obtain credence in the 
light of modern pathology, yet Broca reports sixteen deaths from 
cancer in one family, aud Friederich, a congenital epithelioma in the 
child of a cancerous woman. 

The disease is eminently one of advanced years, being most fre- 
quent after the fortieth year, and a pathological curiosity in child- 
hood. Kaposi reports one case at the tenth year. Only about thirty 
per cent, of all cases occur in women, a fact possibly explained by 
the relative infrequency of the action of local irritants in those who 
are not subjected to the exposure incidental to the trades and severe 
occupations of life. 

These figures, however, relate only to cancer of the skin, since, 

' St. Bartholomew's Hospital Reports, p. 87, 1874. See also the paragraph devoted to this subject 
under the title of Eczema, p. 307. 



CAROINOMA. . 567 

when cases of cancer of the breast and uterus are included, the pro- 
portion of the sexes affected is almost exactly reversed. 

In favor of the local origin of all epitheliomata, is the clinical fact 
of the excellent general health of most patients in the earliest stage 
of the malady; while those affected with syphilis and tuberculosis 
are usually exempt. 

Pathology. — The histological forms of epithelioma are well classified 
by Vidal, 1 as follows: 1. The interpapillary form, in which cy in- 
drical or peg-like epidermal prolongations flatteued at the periphery, 
penetrate downward from the rete, often in parallel columns, between 
the papillae of the corium, and are occasionally connected below by 
a species of anastomosis. Here, at times, onion-like "globes," 
" nests," or clusters of concentrically arranged epithelial masses are 

Fig. 76. 









ri (. 



v 



.. . 

Epithelioma, vertical section a, d, cones of the rete projecting downward ; between these are 
seen atrophied papillae 6; at e, d, and other points, are "nests" of epithelium ; c, atrophied stratum 
■corneum. (After Kaposi.) 

to be recognized, the centre, as Heitzmann remarks, being too often 
occupied by epithelium in a state of fatty degeneration. In this 
way the derma and subcutaneous tissue may be, after previous vascu- 
larization, completely invaded. 2. The lobulate form, in which the 
epidermic globes are in pronounced excess, forming distinctly defined 
masses invading the connective tissue. Here multiplication of the 
elements is abundant, thus diminishing or occluding the lumen of 
the vascular elements, and leading to necrobiosis and ulceration. 3. 
The tubular form, cylindroma of Billroth, the adSnome sudoripare, 
of Verneuil. In this, tubes like sweat ducts with a calibre, penetrate 
the meshes of the connective tissue, often intermingled with epidermic 
globes. It is largely this form of the disease which Tilbury Fox 
and T. Colcott Fox 2 have recognized as originating from the external 
root sheath of the hair-follicle. 4. The pearly form, which Heitz- 
mann has demonstrated to result from fatty degeneration of the 
epithelium in the centre of a "globe" or "nest." 

With regard to the secondary structural metamorphoses of epithe- 

1 Gazette des Hopitaux, Nos. 113 and 114, 1879. 

2 Trans, of the London Path. Soc, 1879. 



568 DISEASES OF'THE SKIN. 

lioma, these are described by Heitzmann as due to fatty defeneration 
of the epithelium, which process may result in its calcification. 
Waxy degeneration of both epithelium and connective tissue pro- 
duces the appearance of shining homogeneous masses within the 
tumor, which are characterized by a noteworthy indifference to the 
action of chemical reagents. Colloid and adenoid metamorphoses 
follow the breaking apart of already formed cancer epithelium, into 
medullary elements from which myxomatous tissue arises. Cystic 
cancer is a higher development of the colloid form, where the myxo- 
matous tissue in the alveoli liquefies. The papillary forms are 
exuberant growths of circumscribed portious of the tumor toward 
and beyond the surface. 

Briefly, every column, "nest," "globe," or tubular prolongation 
within the skin, containing within itself an irregular admixture of 
epithelium and connective tissue, is a cancer, or epithelioma, whose 
gravity seems to be proportioned to the relative development of the 
contained epithelium. As to the origin of the latter, Heitzmann is 
in accord with Virchow in affirming the fact of its production from 
connective tissue. The medullary elements into which connective 
tissue is transformed as the result of an inflammatory infiltration, 
have been traced in the process of metamorphosis into cancer epithe- 
lium. Once fully developed, the neighboring lymphatics are invaded, 
and secondary involvement of the viscera may follow. These minute 
epithelial particles of the neoplasm are swept into the lymph ganglia, 
thence through the lymph to the bloodvessels; where finally, lodged 
in capillaries with a narrow 7 lumen, they produce embolism. 

The malignant forms of cancer may undergo changes by which 
they are transformed into sarcoma. In these, the epithelia become 
gradually indistinguishable as such, in consequence of a species of 
liquefaction by which they are converted into medullary elements. 

Geber explains the pathological changes as follows : 1. Enlargement 
of cones of the rete, the peripheral epithelium becoming cylindrical; 
the central, showing cubic and rhombic, or flat, compressed, poly- 
gonal, dentated, and spinous elements. There are multiple nuclei, 
nucleoli, and vacuoles. 2. The sprouts of epithelium passing into 
the connective tissue become so long, flat, and abundant, that the 
products of secondary inflammation choke them at one point or 
another, so that separation occurs, and the isolated part becomes a 
brood-nest for one or several cancer colonies. 3. The cylindrical form 
of the cells is either then not visible or rudimentary in character, 
the cells and nuclei dividing. 4. There is dichotomous division of 
the smaller and infiltrated papilla?, projected beyond the general 
surface of the skin, producing thus the papillary form of cancer. 
Or, the irritation progressing pari passu with the proliferation of 
epithelium, the corium is uniformly infiltrated with round cells, the 
connective tissue corpuscles multiply, the vessels dilate, and the cells, 
constituting their parietes, proceed to further development. 

When the epithelioma originates in the deeper structure of the 
corium, a round-celled proliferation affects all the epithelial structures 



CARCINOMA. 569 

in the cutaneous glands and hair-follicles, as well as in the deeper 
portions of the rete mucosuni. The epithelial cones are large and 
increase out of proportion to the stroma of the cancer-tumor, which 
is, therefore, softer and more juicy. The bloodvessels and lymphatics 
multiply, especially in the rapidly growing nodules. As the disease 
advances, nervous, muscular, cartilaginous, osseous, aucl other tissues 
may undergo a cancerous transformation, or be simply eroded before 
the inflammatory and pressure effects of the growing neoplasm. 
Occasional terminations of the disease are by exfoliation, ossification, 
calcification, fatty metamorphosis, and sloughing en masse. 

Diagnosis. — Epithelioma is to be distinguished from lupus vulgaris 
approximately, by the age of the patient, the latter disease rarely 
appearing after the thirty-fifth year where there is not a scar or 
history of its earlier existence. Lupus is, at an earlier period of its 
career, more diffuse than epithelioma; its elementary lesions are 
more distinctly groups of individuals than a homogeneous aggrega- 
tion ; its ulcers are more often bordered by outlyiug non-ulcerative 
papules, furnish a more puriform discharge, and, most distinctive of 
all, are never walled about by the firm, densely indurated, often 
everted lip of the epitheliomatous ulcer, opening out often to a sound 
peripheral integument. The peculiar and often characteristic odor 
of the cancer discharge, is absent in lupus. 

From syphilis, epithelioma is to be distinguished : first, by the 
age of the patient, syphilis being decfdedly a disease of early[and 
middle life ; second, by the far greater relative rapidity of the syphi- 
litic process, exception being always made of tertiary gummatous 
ulcers upon the lower extremities persisting for years when there is 
both lack of internal treatment and local support ; third, by the 
history of the disease in each particular case ; and fourth, by the 
characteristic syphilitic features always present in infected individuals, 
including multiplicity of lesions, typical cicatrices, contour of ulcers 
(that of epithelioma is rarely either reniform, horse-shoe shaped, or 
crescentic), character of discharge, and general absence of pain. A 
very important point to note is a marked tendency to reparative 
cicatrization in old syphilitic ulcers, partly due to the exhaustion of 
the infective poison, partly to the influence of the insufficient but yet 
modifying treatment so common in this country. This is exceedingly 
rare in epithelioma, the latter being often, the former rarely, a 
malignant disease. 

Epithelioma of the genitals is not to be confounded with chancre, 
or syphilitic tubercles of that region. The peculiarities of the con-, 
sequent adenopathy in each case ; the lancinating pains of the cancer ; 
its much more prolonged duration ; and occurrence in an aged sub- 
ject, with the general history of the case, will usually point to the 
truth. 

Sarcoma is characterized by : its far more rapid evolution, tumors 
often attaining their maximum of development in the course of a few 
months ; its occurrence by predilection in earlier life ; its inaptitude 



570 DISEASES OF THE SKIN. 

for ulcerative degeneration ; and its marked tendency to multiplication 
in contiguous or distant portions of the body. 

The warts, neevi, excoriations, and seborrheic lesions, from which 
epithelioraata often take their origin, cannot be determined as having 
such a tendency before the cancer has attained some development. 
Every such persistent and long irritated lesion on the person of a 
male subject of advanced years, should be regarded with a degree of 
suspicion. 

Treatment. — No internal treatment of cancer of the skin is known 
to exert the slightest influence upon the growth. 

The treatment of epithelioma is by excision, erasion, or destruction 
of the growth. The first is performed by surgical ablation with the 
bistoury, after which one of the plastic operations may be required 
for either the complete covering of the wound, or the relief of the 
resulting deformity. The second is applicable only to the less formid- 
able growths, and is performed by the aid of the dermal curette. 

Destruction of cancerous tumors of the skin is usually performed 
by the aid of caustics, of which caustic potash, in stick or solution, 
is, perhaps, the most valuable, as its destructive action may be con- 
trolled by the topical employment of acids, and is followed by less 
pain than some other chemical agents. Other caustic substances 
employed for a similar purpose are, chloride of zinc, Vienna paste, 
nitrate of silver, arsenical paste, and pyrogallol. The latter is recom- 
mended highly by Kaposi, not only because its application is un- 
productive of pain, but also because it does not attack sound tissue. 
It is used in an ointment of ten per cent, strength. All such pastes 
aud ointments should be spread upon cloths, and applied for from 
three to six days. Opiates may be required, in the case of several of 
these agents, to relieve the consequent pain. 

Among the formulas used for caustic purposes are the following : 

R . Creasoti ,^ss ; 16 

Acid, araenios. gr. iv ; 266 

Opii pulv. gr. ij ; 133 M. 

For employment upon circumscribed surfacea. [Kaposi.] 

Marsden's paste, also employed as a caustic, is made by combining 
equal parts of gum Arabic and arsenious acid with water sufficient to 
make a softish paste. It is preferred by Robinson to others, and is 
applied on rubber plaster. 

Cosine's paste, as modified by Hebra, is prepared as follows : 

R. Acid, araenios. gr. vj ; 140 

Hydrarg. sulphuret. rub. 3ss ; 2| 

Unguent, aq. ros. ,$ss ; 16 M. 

Sig. Arsenical paste. 

The method of its application is as follows : The paste is spread 
over a thin sheet of lint to the thickness of a knife-blade, and the 
lint then cut to a shape and size corresponding with that of the tumor 
or ulcer to be destroyed. After its close apposition with the surface 
to be attacked, it should be covered with gutta-percha, or other 



CARCINOMA. 571 

impermeable tissue, and a compress laid over the whole. The dress- 
ing is removed, the parts washed clean, and the same application 
renewed in tweuty-four hours. By the third or fourth day, the 
destruction of the cancerous growth is usually complete, and the 
parts are ready for an emollient poultice, which should be applied 
for the three or four days during which the separation of the 
sloughs occurs. The simple ulcer left, is to be treated on general 
principles. The danger of arsenical poisoning is here reduced to a 
minimum ; the treatment being very effectual where patients consent 
to the delay as to time and to the very severe pain which it occasions. 
It has been used by me with satisfactory results, and is highly 
praised by Atkinson 1 in an admirable lecture on epithelioma, deliv- 
ered by him in the University of Marylaud. 

The thermo- and galvano-cautery also may be often advantageously 
used for the destruction of the growths. I have used the former by 
preference in many cases, occasionally without, often with, return of 
the neoplasm. Its advantages are : the transitory character of the 
induced pain; the coal-like dressing left upon the attacked surface; 
and the elegance of the resulting scar. Both measures find their 
highest value when employed after effectual excision or erasion. 

Whatever method be employed, thoroughness is essential in attack- 
ing all portions of the new growth ; and it is well to encroach some- 
what upon the unaffected contiguous structure. The subsequent 
dressings should be made with simple' or carbolated unguents, to 
which one of the salts of morphia may be added in case of continuous 
pain. The eschar usually separates in the course of a few days, 
leaving a simple grauulating wound which may cicatrize soundly, 
and the epithelioma be thus radically relieved. In other cases, the 
disease reappears in the ulcer or cicatrix ; or by recurrence of can- 
cerous nodules in the previously sound integument. Even after 
these recurrences, prompt destruction of the new growth may be 
finally successful. 

But little confidence is placed upon any external treatment which 
does not effect the complete destruction of the neoplasm. Yet there 
are those who highly esteem some of the procedures which are less 
radical in their aim. It is proper to mention these. 

There can be no doubt whatever that some circumscribed and 
relatively small growths disappear under the hot-water treatment. 
The sole question which then arises concerns the possibility of spon- 
taneous recovery in such cases irrespective of the treatment pursued, 
since such spontaneous involution is a clinical fact, rare of occurrence 
though it be. By this method, the neoplasm is sponged with hot 
water for from fifteen to twenty minutes every three hours of the 
day, and oftener if possible, for three weeks in succession. The 
water is as hot as can be tolerated, and applied by the aid of a bit of 
sponge mounted on a probang. During the course of the application, 
water in a state of ebullition, is added in small quantities to that in 

i Reprint, in Chicago Med Journ and Exam., Aug. 1880, p. 188, from the Virginia Medical 
Monthly. 



572 DISEASES OF THE SKIX. 

which the Bponge Is dipped from minute to minute, thus keeping the 
temperature at the highest tolerated point, [mmediately after each 

application, the pan is thoroughly dried, and then cither anointed 
with a bland unguent or completely covered with iodoform in powder. 
When Buch applications are of service, the good effect will usually be 
noted in a week. The ulcer changes its aspect in color, edges, and 
floor; and the pain, if any have existed, is greatly relieved. Granu- 
lation- dt';i healthy type appearand the lips of the sore contract. 
Non-ulcerated lesions shrink iu volume, and otherwise change in 
feature. This system of" parboiling" has the advantage of not pre- 
cluding the ultimate employment of radical measures. The largest 
epithelioma completely relieved by this method, was of the type of 
the "rodent ulcer," on the temple of a male patient seventy-two 
years of age. It had the size of a section of a small hen's egg. The 
resulting cicatrization was satisfactory in all respects. There has 
been no return in two years. Needless to say, the method will often 
fail. 

Leveque, 1 Vidal, 2 Bergeron, 3 Euthyboule, 4 and others claim large 
success in the treatment of epithelioma by chlorate of potash. 
Locally, the part is frequently touched with a saturated solution of 
the salt in glycerine and warm water, after which a simple ointment 
dressing is applied. Vidal administers also the same drug internally, 
in doses of a drachm and a half (6.) in syrup and water before 
meals. It is possible that auy remedial effect obtained from such 
measures should be attributed to the fomentations employed. 

Latterly, benzole has been reported as a valuable topical applica- 
tion to small-sized epitheliomata. The author has employed it in 
several cases with no very marked results. 

Injections of solutions containing copper-sulphate, iodine, alcohol, 
acetic acid, nitrate of silver, chloride of sodium, and hydrochloric acid 
have been practised, it is claimed, with some success ; certainly at 
times with fatal results. The method is unquestionably inferior to 
others described above. 

Prognosis. — In general, it is scarcely necessary to say that the 
prognosis of cutaneous cancer is grave. The relative degree of 
gravity will, of course be largely proportioned to the variety, form, 
size, career, and complications of the growth in each case. The 
variety in which "pearls" only form in the skin is the most benign 
of all, as the lesions are usually isolated, and often, when uuirritated, 
undergo spontaneous exfoliation. In other cases, the disorder for 
from fifteen to twenty years seems to make no progress of any sort. 
The malignity of a cancerous growth is always proportioned to the 
quantity of epithelium contained in its alveoli as compared with the 
connective tissue present; the more abundant the latter, the more 
favorable the prognosis. Naturally, also, the deeper and the more 
destructive the growth, the fewer are the chances of ultimate recovery. 
Excessive pain and adenopathy are unfavorable symptoms in any 

l Glasgow Medical Journal, 1881. s Loc. cit. 

3 Acad, de Med., Paris, 1873. « These de Taris, 1877. 



CARCINOMA. 573 

case. Koch 1 gives some interesting statistics of the results of opera- 
tions, at the Erlangen Clinic, for removal of epithelioma of the lower 
lip, in one hundred and thirty-one patients exhibiting primary lesions. 
One hundred and fifteen were for the time " cured ;" four had speedy 
relapse ; and three were, at the date of writing, living and suffering 
from recurrence of the disease. The prognosis was thus absolutely 
favorable in but twenty-eight cases. 

Cancer of the Connective Tissue. 

This is rare as a primary cutaneous manifestation, but appears 
generally as secondary to a cancerous involvement of other organs, 
as of the female breast. It is termed also Scirrhous, Hard, 
Fibrous, or Lenticular Cancer. It occurs either upon the skin 
covering a breast which has been previously transformed into a can- 
cerous mass, or as a cutaneous relapsing lesion after the extirpation 
of the latter. Its symptoms are pea- to bean-sized, densely firm, 
shining nodules, varying in color • or a more or less diffuse infiltra- 
tion of the skin of similar characteristic hardness, associated often 
with hypersemia of a purplish-red shade. 

A very interesting case of widely disseminated lenticular cancer of 
the skin, illustrated by an excellent portrait, is described by Dr. P. 
A. Morrow, 2 occurring in a healthy-looking woman as a secondary 
phenomenon after removal of primary cancer of the breast. The 
lesions were closely set, small, shining, -firm, red papules ; erythema- 
tous redness ; miliary and pigmented deposits, tubercles varying in 
size ; subcutaneous nodules ; ulcers, crusts, and cicatrices. 

When the cancerous infiltration is widely diffused and indurated, 
involving at once a large portion of the integument of the thorax, the 
condition is produced which is termed by the French cancer en 
cuirasse. This infiltration also is usually secondary to involvement 
of other organs ; but, according to Cornil and Besnier, 3 it may first 
develop in the skin. Pathologically, the form of carcinoma here 
described is also epitheliomatous, since its fibrous stroma always 
contains, in the centre of narrow alveoli, a relatively small number of 
epithelial bodies. It is usually slow of development, but in the end 
accompanied, as are other cancerous tumors, by adenopathy, pain, 
and ulcerative changes, which induce an inevitable cachexia. Like 
the other varieties also, relapse after extirpation is common, and the 
prognosis is proportionately grave. 

Tuberose Carcinoma 

is a rare manifestation of the disease, occurring in the form of mul- 
tiple, firm, peanut- or egg-sized, roundish nodules, which break down 
by ulcerative ■processes into deep losses of tissue. It is frequently 
accompanied or followed by cancerous involvement of other organs. 

i Centralblatt f. Chirurg., 1881, No. 40. 

2 Journal of Cutan. and Vener. Diseases, June, 1884, p. 1. 

3 Bulletin de la Soo. Med. des Hop., 1878, p 158. 



574 DISEASES OF THE SKIN. 

It occurs chiefly upon the face, hands, anus, and chest, though also 
upon other portions of the skin of persons of advanced years, either 
as a primary or secondary cancerous manifestation. Gurnard 1 reports 
the ease of a cancer of this variety, remarkable lor the small size of 
the existing nodules, which varied from that of a hempseed to a pea. 
They covered the entire thorax, back, and right arm, and had here 
and there broken down into ulcers. One of the latter was as large as 
the hand. 

Melanotic or Pigmented Carcinoma 

is that form in which both the epithelium and connective tissue 
framework of the cancer are richly supplied with bloodvessels, and 
probably, as a consequence of transudations from the latter, an abun- 
dant supply of pigment granules in groups and clusters. These 
growths usually begin as hempseed- to pea-sized, single or numerous, 
soft or dense nodules, which may develop in time to tumors of con- 
siderable size, and are stained in various shades from a grayish-brown 
or a slate-color to a dead black, the pigment being occasionally dis- 
played irregularly in streaks or bands over the surface of the growth. 
They occur over any portion of the surface, ofteuer upon the extrem- 
ities and genitals, starting frequently from benign pigmentary lesions, 
such as noevi and moles. Anatomically the pigment is found to be 
deposited both between the cells and in the protoplasm of the cells 
themselves. 

The author has, in a few instances, seen the disease limited to single 
melanotic growths of this character. The cancer is apt to develop in 
the papillary form, furnishing thus fungoid vegetations which have a 
noteworthy tendency to degenerate into ulcers. Often such verrucous 
masses are seen surrounded by grayish or blackish papules, or by a 
diffuse cancerous infiltration of the integument, exhibiting irregular 
pigmentation of the surface. The disease is apt to appear in the 
viscera, in the form of disseminated cancerous nodules, each highly 
vascular, and exhibiting in varying quantity granules of pigment. 
The growth has usually a relatively rapid course and malignant 
career. Relapses are frequent, the amount of pigment usually 
increasing with each relapse. A nut-sized melanotic cancer of the 
skin, removed from the hand of a patient in Chicago by one of the 
author's colleagues, was not followed by other manifestations of the 
disease during the ensuing year. At the end of that time the patient 
passed from observation. 

1 Union ^UmI., February 5, 1881. 



SARCOMA. 575 

Sarcoma. 

Gr. cap!;, flesh. 

Sarcoma of the skin is characterized by the occurrence, either as primary or 
secondary developments, of single or multiple, pea- to egg-sized and larger, 
pigmented and non-pigmented, cutaneous and subcutaneous neoplasms- 
having a marked inaptitude for ulceration but malignant in character, 
recurring after extirpation, and usually terminating fatally with involve- 
ment of the viscera. 

The term Sarcoma, meaning a fleshy tumor, was originally em- 
ployed by Virchow in the designation of this disease. Its anatomical 
features have been carefully studied since by Rindfleisch, Cornil and 
Ranvier, Babes, Heitzmann, and others. 

Symptoms. — The disease, when affecting the skin, is characterized 
by the appearance of one or several, usually at first isolated, pea- to 
nut-sized and larger, smooth, spherical, irregular, or lobulated, 
cutaneous or subcutaneous tumors. They may or may not be at first 
attached to the epidermis above and the deeper structure beneath, but 
eventually contract such adhesions. Between them the skin may not 
be involved. In uncomplicated cases at this period, the conspicuous 
features of these lesions are (a) their whitish color, due to their 
envelopment in an UDaltered epidermis ; (b) the history of a rela- 
tively rapid development, as distinguished from fibromata, epithelio- 
mata, gummata, and lupous tubercles; (c)the speedily declared sys- 
temic results of the growth. 

Later, the skin between the lesions becomes swollen, infiltrated, 
painful ; and, even before the tubercles desquamate, enormous tume- 
faction and redness of an erysipelatous type may affect the inter- 
nodular tissue. In this way an entire limb, only one portion of 
which is the seat of the tubercular growth, may attain an elephanti- 
asic size, ulcerate at one or more points, and pour out an offensive 
secretion as a consequence of ulceration of the inflamed integument. 

In the course of time, weeks not years, the nodules or tumors of 
sarcoma coalesce, degenerate by ulceration, and participate in the 
process of secretion going on in the inflamed and excoriated surface 
of the skin where they are implanted. Death speedily results, either 
from exhaustion, intercurrent fever, or sarcomatous involvement of 
one or several viscera. By the same process the skin lesions may be 
the product of metastasis from the lymphatic glands or viscera. 

The disease occurs in this form over the chest, extremities, and 
genitalia, though all parts of the skin have been invaded. The 
patient from whom the tumors were removed, whose microscopical 
features are represented in the accompanying illustration, was a 
woman in middle life. 

The disease is both rapid in course and malignant in type. In a 
total of more than fifty thousand cases of disease of the skin reported 
to the American Dermatological Association up to 1882, only sixteen 
were sarcomatous, the actual percentage being 0.027. 



576 



DISEASES OF THE SKIN. 







The Etiohf/y of the disease is unknown. 

According to Babes, sarcomata are frequently congenital, and not 
rarely formed in early youth on the lids, extremities, and genitalia. 
Pathologically, according to the same author, sarcomata are 

new-formations of embryonal 
Fig. 77. tissue with abundant prolifera- 

tion of vascular elements and 
vessels As to the former, nume- 
rous rudiments of vessels mul- 
tiply without developing into 
complete vascular channels, 
ofte\i making eventual connec- 
tion with preexisting vessels. 
In these there may be a com- 
plete or incomplete development 
of blood. In other cases, the 
parietal portions of young blood- 
and lymph-vessels proliferate 
abundantly in an embryonal 
formation of fasciculi and alve- 
oli, either choking the lumen of 
the original vessel, or transform- 
ing it into vacuoles, cups, and 
spaces. 

All tumors of this character 
are abundantly supplied with cells, the proportion of which to the 
stroma is markedly in excess. They never resemble embryonal and 
granulation tissues. The cells may be spindle-shaped, spheroidal, 
branched, with one or many nuclei, and either large or small. The 
fibrillar basement-substance, according to Delafield and Prudden, 1 
may be present in such small quantity as entirely to escape superficial 
observation ; or so abundant as to suggest the appearance of a 
fibroma. It may be closely inwoven with the cells in such bundles, 
or exhibit wide and open meshes presenting the appearance of alveoli. 
The cells are in intimate relation, and often continuous with the 
basement-substance. Both cells and substance are in the same close 
relation with the vascular elements described above, upon which 
Babes relies so largely for identification of the nature of the growth. 
Virchow described originally five varieties of sarcoma : round- 
celled, spindle-celled, net-celled, giant-celled, and melanotic. In 
spindle-celled sarcoma the cells may be large or small, and vary so 
greatly in proportion to the stroma as to furnish the sub variety of 
fibro-sarcoma, in which the fibrous tissue abounds between the cells. 
These may be encapsulated or infiltrating. The mass of the tumor 
is then constituted of a decussating felt-work of spindle-shaped, 
nucleated, protoplasmic bodies. 

Round-celled sarcoma is constituted of globular, protoplasmic ele- 



Sarcoma. Spindle-cells visible in sections of 
cutaneous nodule removed from one of the authoi 
patients. (About X 300.) 



1 Handbook of Pathological Anatomy and Histology, Sew York, 1S85 



SARCOMA. ■ 577 

ments closely packed together, and separated by a very narrow layer 
of cement-substance, traversed by delicate prolongations of the living 
matter which uninterruptedly connect the elements. The vascular 
supply is scanty. There are two forms of this growth found in the 
skin : (a) Those with relatively large protoplasmic bodies and large 
nuclei — large round-celled sarcoma. (6) Those with relatively small 
homogeneous lumps of living matter — small round-celled sarcoma or 
" lympho-sarcoma." The last-named varieties are, as a rule, more 
rapid in growth and more malignant in career than the former. 

In the "alveolar sarcoma" of Billroth there is a delicate connective 
tissue framework, containing attached globular or pyri-form bodies. 
Heitzmann has recognized this form once, in the skin of the left groin. 

The compound varieties of the disease, myxo- and fibro-sarcoma, 
are occasionally seen in the skin. The formation of secondary 
tumors is explained, according to Heitzmann, by the transmission of 
minute particles of the neoplasm to capillaries of a fine lumen, pre- 
sumably through the bloodvessels, as the lymph ganglia are rarely 
involved. 

The diagnosis rests upon microscopical examination of the new 
growth in every case. Sarcoma should not be confounded with 
fibroma, epithelioma, gummata, or lupous nodules. 

The treatment is highly unsatisfactory. The surgical ablation of 
these tumors is apt to be followed by their speedy return. 

The prognosis is exceedingly unfavorable, a fatal issue occurring 
in most cases. 

Melanotic Sarcoma, or Melano-sarcoma of the skin may be 
of primary occurrence or develop from a nsevus pigmentosus. The 
lesions are bean- to egg-sized, single or multiple, firm or doughy, 
sessile or pedunculated, spheroid or tabulated ; and vary in color 
from grayish-brown to deep black. The epidermis which covers 
them may be discolored, thinned, and intact or ulcerated. The secre- 
tion may be of any shade to an inky blackness. The nodules are often 
surrounded by blackish puncta which eventually develop into tubercles. 

In a case lately observed by the author, the left lower extremity of 
a middle-aged woman was studded with split pea-sized to marble- 
sized, ink-black masses from the ankle to the middle of the thigh. 
The larger were always centres of groups of similar pin-head sized 
black masses. The skin of the region affected was swollen, inexten- 
sible, inelastic, and as firm as sole-leather. The disease had rapidly 
extended from the ankle upward in the course of a few months. 

Pathologically, tumors of this kind are found to exhibit the ana- 
tomical features of sarcomata in general, with pigment distributed 
both within and between the cellular elements of the tumor, and 
between the fasciculi of connective tissue in the framework. It is 
one of the most malignant and rapidly fatal of all neoplasms. 
Therapy is unavailing ; and the prognosis is grave indeed. 

37 



578 



DISEASES OF THE SKIN 



Mycosis Fungoides. 

Gr. /nw/f, a mushroom. 

Mycosis Fungoides is an infective disease, characterized by various cutaneous 
phenomena which result finally in the production of one or several well- 
defined, firm, reddish tumors, probably due to the presence[of specific micro- 
organisms. 

This disease, first named by Alibert, lias also been termed, Granu- 
loma Fungoides, Granuloma Sarcomatodes, Lymphadenie Cutauee, 
Inflammatory Fungoid Neoplasm, and Eczema Tuberculatum. 

Symptoms. — The disease is often preceded by the occurrence of 
inflammatory changes in the skin, erythematous, eczematous, psori- 
asiform, urticarial, or lichenoid, which may be transient and recur, 
or persist. Eventually the skin becomes infiltrated, thickened, and 
decidedly pruritic. In either case, the characteristic lesions of the 
disease develop upon a sound integument. 

Fig. 78. 



U " ,' W" A'\> , ^ ; 







• 






v ^ 



(Drawn from an oil painting taken at the bedside of one of the author's patients.) 

In a variable period of time, the characteristic tumors of the disease 
appear upon the face, scalp, chest, or other portions of the body. 
They are bean- to palm-sized ; whitish, pinkish, or pale reddish in 
hue; firm, well rounded, and distinctly circumscribed. Often they 
are like flat buttons, movable within the skin. They may theu dis- 
appear by absorption while others appear; may degenerate by erosion 
leading to superficial ulceration ; or may melt down into deep losses 
of tissue by ulceration. Coiucidently the lymphatic glauds may 



MYCOSIS FUNGOIDES. 579 

enlarge and this adenopathy, as in case of the tumors, subside to be 
replaced later by similar involvement of the same or other glands. 

When the tumors have attained maturity and before involution 
has begun, their appearance, especially upon the face, is characteristic. 
They are smooth, moderately firm, sausage-like in shape, often 
lobulated, of a peculiarly reddish hue, and produce when numerous 
a lepra-like deformity, closing the eyes by their size or weight, pro- 
ducing the leonine brow and the elephantiasic ear. In the author's 
case illustrated in the cut 1 the body of the patient was extensively 
covered with tumors of all sizes, resembling those seen upon the face. 

The general condition of the patient at first seems unaltered ; 
later, when the tumors ulcerate, exhaustion occurs and the victim 
usually dies, as in other cutaneous disorders of similar gravity, as a 
result of febrile processes, or of an intercurrent diarrhoea, or of 
cachexia. When the tumors are many and the ulceration extensive, 
the appearance of the patient is repulsive in the extreme, the exhala- 
tions from the body in the highest degree fetid, and the difficulty 
of securing antisepsis, hygienic care, and comfort for the wretched 
sufferer well nigh insurmountable. 

The fully developed tumors occur upon all parts of the body, 
more particularly upon the palmar and plantar surfaces, the fore- 
arms, the legs, the face, and the back. Often they are in various 
degrees pigmented, showing then purplish, brownish, or even black 
colors. They are usually painful, and may or may not be tender. 
They sometimes, after disappearing, leave atrophic or pigmented 
depressions as relics of their career. They are said to ulcerate 
rarely. In the author's patient, ulceration attacked some of the 
tumors, leaving crateriform excavations in their centres, but this was 
an exception to the rule, the larger number present preserving their 
shape in death. In a few, vegetations appeared upon the summit, 
smeared with a thin and very offensive secretion. 

When the tumor is single, and apparently uncomplicated by in- 
volvement of deeper organs, extirpation is usually followed by recur- 
rence, either in the scar or vicinity, with added malignancy. 

On the backs of the hands the lesions may be no larger than small 
marbles, with infiltration of the skin lying between the latter, pro- 
ducing thus the appearance of a small, well-rounded, cushion. The 
epidermis of such an cedematous hand usually exfoliates in silvery- 
white or grayish scales, more or less adherent. The feet and legs 
may exhibit a similar appearance. 

The disease has been studied abroad by Ilebra, Kaposi, Geber, 
Alibert, Fox, Kobner, Auspitz, and others; in this country by 
Duhring, Piffard, Wigglesworth, Tilden, 2 and the author. 

Etiology. — The disease is fortunately rare. Dr. Tilden collected 
the records of thirty cases of the disease and of sixteen deaths. 
Twenty-three patients were males, and seven females ; more than 
half the whole number were over forty years of age; in only one 

1 Edinburgh Med. Journ., 1883-1884, xxix. p. 592. 

2 Consult Dr. Tilden's admirable monograph on the subject, in the Eostou Med. and Surg. Journ. 
of Oct. 22, 188o. 



580 DISEASES OF THE SKIN. 

fourth of the number had the disease developed before the twentieth 
year of life. There can be little question to-day as to its infectious 
character. It is probably produced by a specific microorganism. 

Pathol of hi. — Under the microscope, sections of tumors removed from 
patients affected with the discrise, exhibit infiltration of the corium 
and subcutaneous tissue with small round cells arranged in circular 
or irregular groups, enclosed in a narrow stroma of fine connective 
tissue fibres, with often a centrally situated bloodvessel. The epi- 
dermis, at first spared, is afterward involved by ulceration. According 
to Gannett, who examined sections in Tilden's case, the cells corre- 
sponded, morphologically, to lymph-corpuscles. 

The microorganisms of mycosis fungoides have been recognized 
by Rindfleisch, Auspitz, 1 and others. An exhaustive report on the 
subject has been made more lately by Auspitz's collaborators, Messrs. 
Hochsinger and Schiff; 2 and Professor Firket, 3 of the University of 
Liege, reports yet another case, illustrated by a photograph, in which 
micrococci were recognized. These are diplococci or streptococci, 0.9 
to 1.2 mm. in diameter, and found clustered together both in tumors 
and in bloodvessels. They were found not only in the protoplasm of 
the cells, from ten to twenty in each, but also thickly spread along 
the connective tissue fibres in the neoplasm. These were cultivated 
successfully for a series of generations in gelatine and blood-serum. 
Post-mortem examination has rarely shown visceral involvement. 

The diagnosis of mycosis fungoides cannot be made with certainty 
before the characteristic tumors have been developed. After that, 
the peculiar shape, reddish color, situation, and relative rapidity of 
the growth point to the nature of the disease. 

From lupus vulgaris, with which it may be confounded in view of 
the age of the patient, it may be recognized by its relative rapidity 
of evolution, its failure to ulcerate at an early stage, and the absence 
of cicatrices in cases where there has been no operative interference. 

Syphilis is to be distinguished by its history, its multiformity, its 
ulcerative type, and its amenability to specific treatment. Lepra 
does indeed, when occurring in its rare and acute forms, suggest 
mycosis fungoides of the face. But the presence or history of hyper- 
sesthetic or anaesthetic symptoms, of bullous or macular lesions, and 
the absence of deforming mutilations in advanced periods, will' 
usually point to the nature of the disease. The tubercles of lepra 
are smaller than the tumors of mycosis fungoides; more bronzed and 
less fleshy in color, and of far less general distribution than in several 
cases on record of the last mentioned disease. 

The treatment is unsatisfactory. With the knowledge now pos- 
sessed as to the nature of the disorder, the bichloride of mercury 
would certainly be indicated in the local management of the disease. 

The comfort of the patient is to be secured by all measures, in- 
cluding anodynes in an advanced stage of the disease, and his strength 
should be supported by a generous diet and tonic regimen. When 
the disease is generalized, tepid baths are productive of great comfort, 

i Yicrtl. f. Derm. a. Byph , 1885. 2 Ibid., 1886. 

3 Ann. do. la Soc. Med'. Chir. de Liege, 1886. 



PRURITUS. 581 

and the use of carbolic acid, or some similar agent, is indicated by 
the fetor arising from the person. The body should be anointed 
with a bland unguent after each bath. When the lesions are single 
or few, it is doubtful whether extirpation should be practised. 

The prognosis is unfavorable. The patient may survive from a 
few months only to a maximum of twelve years, the average being 
two to four years. 



CLASS YII. 

NEUROSES. 

Hyperesthesia. 

Gr. virep, above; ala&7jGig, sensibility. 

This is a condition characterized by exaggerated sensibility unat- 
tended by structural changes in the skin. It may be idiopathic or 
symptomatic, general or partial, unilateral or bilateral, and may also 
vary greatly in the degree of abnormal subjective sensation by which 
alone it is declared. In mild cases, there is unusual sensitiveness 
to contact with foreign bodies, such as the clothing; in others, the 
distress occasioned by even the passage of a feather over the surface 
is almost intolerable. The symptomatic variety of the malady is 
most common, occurring as one of the several manifestations of 
hysteria, tetanus, and other nervous disorders, including certain forms 
of motor paralysis where sensation has been retained, though in a 
perverted condition. The disease is properly classed with the 
neurosas of the skin, with respect to whose etiology and pathology 
much remains to be investigated. Its chief manifestations are the 
production of itching and pain. 

The former is in the skin much more frequently experienced than 
the latter ; and is an almost constant symptom of active cutaneous 
hyperemia and exudation. The parassthesia? (in which sensations of 
heat, formication, tickling, dripping or pouring of liquids of various 
•temperatures are experienced) are more often associated with extra- 
cutaneous affections. 

Pain, solely and simply limited to the skin, is, in fact a neuralgia 
of a nerve having a cutaneous distribution. 

[A.] Pruritus. 

Lat. prurire, to itcb. 

Pruritus is a functional disorder of the skin, characterized by the sensation of 
itching in a part or a whole of the body, and unaccompanied by objective 
symptoms of disease. 



(oms. — Pruritus is to be distinguished not only from prurigo, 
a rare disease of the skin already described, but also from the symp- 
tomatic sensation of itching: which is occasioned bv a number of 



582 DISEASES OF THE SKIN. 

cutaneous disorders, such as eczema, scabies, and those produced by 
pediculi. Hebra was firsl to recognize the independent character of 

the disease here considered ; and it i- perhaps to be regretted that he 
did not give to it a name distinct from that which is also applied to 
a symptom common to several maladies of the skin. 

Pruritus is characterized by a sensation of itching not produced 
originally by cutaneous lesions. It may be general or partial. In 
either form, it begins usually by a tickling, pricking, crawling, or 
itching sensation in the skin, which solicits the sufferer to rub, press, 
scratch, or otherwise irritate the affected integument. It usually 
occurs by accesses in the day or night, much more often the latter, 
occasionally both; and these accesses manifestly occur under the 
immediate stimuli!.- of some internal or external cause. Thus moral 
emotions, a cool draught of air, the warmth of the bed, the pressure 
of clothing, and often the substances applied externally with a view 
to the relief of the pruritus, suffice to determine a crisis. However 
firmly the sufferer may determine to avoid injury to the person, in 
well-marked cases the impulse to scratch becomes well nigh irresis- 
tible, and, in the highest degree, tormenting. From the milder, the 
patient will thus be frequently teased to inflict the severer injuries 
upon the skin. Brushes, combs, coarse cloths, and even metal instru- 
ments, will be employed in exaggerated cases, for the purpose of 
assuaging temporarily the local distress. 

The objective cutaneous symptoms which may be presented are all 
secondary, and invariably result from self-inflicted injury. In some 
cases they do not appear, the statements of the patient being the sole 
basis for a recognition of his disease. This may be the consequence 
of unwonted self-control, or of the mildness of the malady, or of the 
transitory character of the lesions produced. Thus the skin may be 
reddened during a nocturnal paroxysm under the manipulation of 
the sufferer, and the transitory hyperemia disappear in the daytime 
when the skin is submitted for inspection. Not rarely, however, the 
integument resents the treatment to which it is subjected, by dis- 
playing wheals, hyperaemic blotches, reddened papules, excoriations, 
characteristic " scratch lines," and the minute blood-crusts which 
indicate that the papillary layer of the derma has been reached and 
slightly torn. As these causes are among those recognized for eczema 
and dermatitis, it is not surprising to note that such disorders of the 
skin may be in this way originated, and still further add to the sub- 
jective distress. Skins which have been for years the seat of a per- 
sistent pruritus leading to traumatisms of the epidermis, are always 
deeply pigmented. 

The localized forms of pruritus, albeit the abnormal sensation is in 
them limited to certain regions of the body, may occasion fully as 
much distress as those in which a larger part of the integument is 
affected. They are of more frequent occurrence than the generalized 
forms. Pruritus of the anus, of the scrotum, of the vulva, of the 
vagina, of the scalp, of the nose, of the mouth, of the axillre, are all 
localized forms of the disease, two or more of which may coexist or 
develop in succession. 



PRURITUS. 583 

Pruritus JSTarium is a frequent symptom of irritation of the 
Schneiderian membrane. It is thus a common precursory or 
attendant phenomenon of rose- or hay-asthma ; and in some indi- 
viduals announces the systemic effect of opium and its alkaloids after 
ingestion. It may result also from the irritation awakened by intes- 
tinal parasites. 

Pruritus Genitalium is often an exceedingly severe and dis- 
tressing affection. As the parts in question are apt to be rubbed and 
scratched in the efforts to secure relief of the itching sensation, orgastic 
effects and pollutions are often produced in early youth and extreme 
age, whose moral effects are degrading. The scrotum, labia majora 
and minora, penis, clitoris, and adjacent cutaneous and mucous 
surfaces may be the seat of the pruritus. Search should always be 
made, in such cases, for ascarides of rectum or vagina, saccharine 
urine, and uterine or ovarian affections. A perverted sexual hygiene 
may lie at the root of these disorders. In the severe cases the violence 
with which the parts are attacked suggests frenzy on the part of the 
patient, who at times is never content till the scrotum or other parts 
are bathed in blood. The thickening, erosions, and excoriations of 
the regions attacked are conspicuous features of the disease. 

Pruritus Ant. — This is a disorder of adults of both sexes, and 
may coexist with pruritus of the genital region. There is usually 
nocturnal exacerbation. The anus may become infundibuliform from 
induration ; its mucous surface excoriated ; its cutaneous borders 
seamed, puckered, eroded, aud fissured. It is often complicated with, 
because the origin of, an eczema whose lesions reach upward over the 
coccyx or forward to the genital region over the perineum. Haemor- 
rhoids, ascarides, chronic prostatitis, rectal impaction, proctitis, 
unnatural vices, and diabetes may be all responsible for its occurrence. 
In all exaggerated forms of pruritus cutaneus, the general health 
perceptibly fails. Whether from prolonged insomnia arising from 
the nocturnal exacerbations to which there are but few exceptions ; 
or from the perversion of nutrition incident to the continuous teasing 
of the nervous system ; or yet from the hypochondriacal state into 
which some patients are plunged by their sufferings, such an issue is 
often to be expected. It is in fact a complication which may merit, 
as much as the disease itself, the attention of the physician. 

Etiology. — The causes of pruritus are numerous, and the necessity 
for the discovery of the particular cause in each patient, often makes 
the largest demands upon the practitioner. The disease may occur 
at all periods of life aud in both sexes, but its exaggerated forms are 
peculiar to middle life and advanced years (Pruritus Senilis). It 
is frequently a reflex symptom of one of several internal disorders. 
Among the latter may be named, malarial affections, tuberculosis, 
carcinoma of the viscera, disorders of the liver or kidneys (especially 
jaundice, Bright's disease, and diabetes), and disturbances of the 
alimentary caual, including those due to intestinal worms, hsemor- 



584 DISEASES OF THE SKIN. 

rhoids, and dietetic or medicinal ingesta. It may be associated with 
almost every one of the functional, and not a few of the organic, dis- 
orders of the uterus and ovaries. The same may be said of its 
dependence upon the genito-urinary diseases of the male sex, includ- 
ing stone in the bladder, stricture of the urethra, disorders of the 
testis and epididymis, and perverted sexual hygiene. 

Lastly, the moral emotions of a depressing character play an im- 
portant part in the etiology of pruritus. Mental distress, occasioned 
by bereavement, separation from relatives, misfortune of all sorts, 
and anxieties as to the future, often find physical expression in the 
disease. 

Pathology. — The disease is essentially a functional disorder of the 
nerves of sensation applied to the skin, and is of itself incapable of 
producing objective symptoms. This fact can, in some cases, be 
clinically demonstrated, as the seat of the pruritus, even though 
exhibiting artificially produced lesions, will, when protected from all 
external injury, speedily regain its normal appearance, the pruritus 
no less continuing. It is probable, though not certain, that the 
nerves also in this disease undergo no structural change, but merely 
convey to the periphery a perverted sensation which is often reflected 
from some centric point of disturbance. 

Diagnosis. — The recognition of general pruritus is usually not 
difficult, as the secondary results of the disease are apt to be less 
marked than in its other forms. The complaint of the patient, the 
absence of cutaneous disease sufficient to explain his symptoms, and 
especially the discovery of such a sufficient cause in some visceral 
or systemic disorder, are all significant. 

One of the most constant features of general pruritus is visible 
only when the clothing of the patient is entirely removed. It then 
becomes evident to the eye that the affected regions are, in order of 
frequency, those most accessible to the hands. The posterior are 
much less involved than the anterior surfaces. The small of the 
back and interscapular regions are usually untouched. The tibial 
regions of the legs and the forearms, suffer more than the calves and 
the upper arms. The lower belly and inner feces of the thighs are 
punished more severely than the breast and outer faces of the thighs 
and the hips. The clavicular regions are more excoriated than the 
back of the neck. There is no more precise evidence than this as to 
the pruritic character of any cutaneous affection, and it is one too 
often ignored by the practitioner who prescribes under those circum- 
stances for a "disease of the blood." 

It must be admitted, however, that when the disease is localized, 
and complicated, as it frequently is, by an eczema or dermatitis, 
obscurity often arises. Attention should then be paid to the history 
of the disorder, which may reveal the fact that the pruritus preceded 
for some time the cutaneous symptoms, and may reveal even more. 
Intelligent patients will often assure the physician of the real nature 
of their malady, by voluntarily remarking that the skin symptoms 
disappear upon the region which is not scratched, though the pruritus 



PKURITUS. 585 

continues. In all cases the operation of exterior agencies should be 
carefully eliminated. 

Prurigo, with its infiltrated skin, its primary papules, and its 
severe itching, beginning in early infancy and commonly persisting 
through life, can scarcely be confounded with pruritus cutaneus. 

Treatment. — The degree of success to be obtained in the treatment 
of pruritus cutaneus, is largely proportioned to the skill with which 
the cause of the disease is recognized and remedied. Taking into 
consideration the number of systemic and visceral disorders which 
may be, in different cases, responsible for the skin symptoms, it is 
clear that an exhaustive study of the mental and physical history of 
each patient will be essential at the onset of treatment. The cause 
once recognized, the treatment should be directed to the special dis- 
order discovered ; and this largely requires the skill of the general 
practitioner. The gastro-intestinal tract, the kidneys, the liver, the 
bladder, the uterus, the prostate gland, the rectum, and indeed any 
one of the viscera, may require therapeutic management. For the 
frequent gastric disorders, the alkalies and alkaline waters, with 
occasional cathartics and strict regulation of the diet, are often useful. 
Attention should be particularly directed to any medication to which 
the patient may have been subjected with a view to a therapeutic 
effect, and which may have aggravated the complaint. The mineral 
acids, chalybeates, pepsin, lactopeptin, quinine, strychuine, phosphorus, 
arsenic, or atropine may be indicated in individual cases and produc- 
tive of favorable results. 

The substances which have been topically employed for the relief 
of puritus cutaneus are almost without number, a fact warranting 
the conclusion that each occasionally fails to afford the desired relief. 
This is corroborated with every wide clinical experience ; that prepa- 
ration, moreover, which is at one time of the highest value, will dis- 
appoint at another period in the history of a single case. Attempts 
to secure relief by such topical applications should, however, be 
always made and will often be followed by gratifying results. 

First in order of value are baths and lotions of water, hot, warm, 
or cold, or alternately hot and cold, and medicated by the addition 
of the sodic bicarbonate or biborate, the potassic carbonate or sul- 
phuret, varying in strength from one ounce (32.) of the last-named 
to six ounces (192.) of the first-named substance, in thirty gallons of 
water. Gelatine or bran may often with advantage be added to 
these, as suggested in the chapter on general therapeutics. Alcoholic, 
ethereal, camphorated, and carbolated lotions are to be regarded as of 
equal value. Duhring specially recommends solutions of carbolic 
acid, in the strength of from five to twenty grains (0.33-1.33) to the 
ounce (32.) of water, to which a half drachm (2.) of glycerine has 
been added. Rohe similarly employs boric acid, one drachm (4.) 
to the pint (512.). 

Van Harlingen adds the anti-pruritic effect of potash as follows : 



M. 



. Acid, carbolici 


3j; 


4 


Potassse fus. 


3ss; 


2 


Aq. dest. 


Oss; 


256 



586 DISEASES OF THE SKIN. 

Baths and lotions of this character usually procure merely tempo- 
rary relief; and the treatment in the interval of their application 
demands the wearing of soft linen, or other unirritating material 
next the skin, and the free use of a dusting-powder. Those of pure 
starch are here less useful than those compounded with oxide of zinc 
and bismuth, as in the "Anderson powder." Gorecki 1 mingles the 
starch with perfectly pure boric acid. 

Dr. R. W. Taylor, of New York, in a valuable paper, 2 gives the 
following formulae: 

R. Potass, sulpkuret. Jiij ; 12 

Camphor, sj.ts. fsss; 16 

Glycerin. Q j ; 32 

Aq. font. q. s. ad f=yj , 192 M. 

Sig. For external use as a lotion, and to be applied by the medium 
of a saturated strip of lint. 

R. Spts. camphor. f^ss; 16 

Boracis ,%ij ; 8 

Glycerin. f% ij ; 64 

Aq. fluv. = vj ; 192 M. 
Sig. To be well shaken and applied externally. 

Morphia, in the strength of one grain (0.066) to the ounce (32.), 
may be added to this and other lotions. 

( Ihloral-camphor, a pungent, syrupy liquid obtained, as suggested 
by Bulkley, of New York, after triturating an equal amount of the 
two substances in fine powder, is an antipruritic remedy of value in 
certain cases applied in a salve containing one drachm (4.) to the 
ounce (32.) of salve, and is comparable in its action to phenol-cam- 
phor, described in the chapter on general therapeutics. 

Other lotions may be made to contain corrosive sublimate, one- 
quarter of a grain (0.016) to the ounce (32.); dilute hydrocyanic 
acid, a drachm (4.) to the half pint (256.); Goulard's extract, a 
drachm (4.) to the pint (512.); chloroform, sulphur, alum, oil of pep- 
permint, dilute nitric, acetic, or salicylic acids, tannin, or the zinc 
sulphate in due proportions. 

Often the aqua calcis, medicated with calomel, zinc oxide, bismuth, 
or calamine, answers well, and, if tolerated at all, the addition of 
linseed oil, four ounces (128.) to the pint (512.), with a drachm (4.) 
of one of the inert substances named, flavored with rosemary or 
bergamot, will aid in relieving the local. distress. 

Ointments and fatty substances in general are usually not well 
tolerated in cutaneous pruritus. Occasionally, however, they are of 
more value than lotions, and may be made to contain one or more of 
the substances named above, such as carbolic acid, five grains to fif- 
teen (0.33-1.) to the ounce (32.); subnitrate of bismuth, a scruple 
(1.33) to the ounce (32.), chloral camphor, five minims (0.33) to the 
ounce (32.), and calomel, five to ten grains (0.33-0.66) to the ounce 
(32.) of cold cream, petroleum ointment, or lard. 

i Le Praticien. Oct. 3, 1881, i>. 473. 

2 On the Various Koruisof Pruritus Cutaueus, and their Treatment, Arch, of Clin. Surg. Kutledge 
& Co., 1877. 



PRURITUS. 587 

Tarry substances are usually not well tolerated in the disease, and 
are, as a rule, when the skin is sound, objectionable as liable to irritate. 
Duhring, however, speaks well of the liquor carbonis detergens, in 
the strength of a drachm (4.) to two ounces (64.) of water. This 
alcoholic solution of coal tar has been for some time in the market of 
our large cities. The liquor picis alkalinus may be similarly em- 
ployed. Special attention has been directed by many writers to the 
treatment of the local forms of pruritus, the principles of which 
have been in the main described above. 

For pruritus of the vulva, Wiltshire 1 recommends decoctions of 
almond meal, marshmallow, slippery elm, and rice ; and in case of 
failure of the latter, an infusion of tobacco two ounces (64.) to the 
pint (512.). Vaginal injections of hot water and tampons or cocoa- 
butter suppositories medicated with opium, belladonna, or carbolic 
acid are also available. 

Many of the medicaments named above are also useful in pruritus 
of the ano-genital region. The application of very hot water is of 
decided service. Exception should be made here to the rule with 
regard to the exclusion of tars generally from the treatment of pru- 
ritus; as in the distressing itching of the scrotum and anus especially, 
they are often essential. The tincture of tar, oil of cade, and oil of 
white birch will here often be needed. Pencilling any existing 
fissures with the compound tincture of benzoin or nitrate of silver, 
is serviceable. The scrotum when attacked, usually requires the use 
of a suspender or suspensory bag, lined with soft lint or borated 
cotton, which may also be incorporated with a dusting powder, wetted 
with a lotion, or smeared with an unguent. 

Simon has successfully employed pilocarpine in cutaneous pruritus, 
both internally and by hypodermatic injection. For the latter, the 
muriate of pilocarpine is used in doses of one-sixth of a grain 
(0.011). The same author has administered with good results a 
syrup of jaboraudi, made in the proportion of three parts of the 
leaves of the plant to fifteen of water, and eighteen of dissolved 
white sugar, of which two tablespoonfuls are taken at a dose. 

In Europe, the favorite local application for relief of pruritus is 
a lotion containing tar in some form. Usually from five to ten per 
cent, of glycerine is employed in a spirit lotion. Salicylic acid is 
often substituted for it : e. g. : 

R. Acid, salicylic. 

Spts. vin. rectif. 

Aq. dest. giij ; 96j M. 

Lotion. 

Schwimmer recommends : 



R. Alumin. hydrat. 
Glycerin. "I 
01'. oliv. J 
Ungt. moll. 

Sig. Ointment 



3"j; 


4 

64 
96 


3jss; 


6 


aa 5v; 


20 


3x; 


40 



M 



Brit. Med. Journ., March 5, 1881, p. 328. 



588 



DISEASES OF THE SKIN. 



Thin lotions of starch-water or oatmeal gruel, iced or cooled in 
hot weather, to each pint of which a drachm or more of the zinc 
oxide, or Bubnitrate of bismuth may be added, are often of immediate 
value. 

Iodoform, the oleate and muriate of cocaine, the latter in from 
two to four per cent, solutions; one ounce (32.) of the fluid extract 
of coca, to two to four of water; and linseed oil (especially for 
pruritus ani), are also recommended. 

Jullieu recommends in pruritus of the vulva : 



R. Zinci oxid. 3yj ; 

Acid, salicylic. gr. xv ; 

Glycerin. 3yj ; 
Sig. Apply as required. 



M. 



Cheron, in pruritus of the vulva attending the menopause, has 
successfully used : 



R. Veratrite 
Axung. 



gr- "J 
5J 



266 



32| 



M. 



He also administers in pill form, one one-hundred-and-twentieth 
of a grain of veratria rubbed up with licorice. 
Squibb's formula is : 

R. Acid, tannic. 9j ; 1 

Glycerin. ) .. _ ir 

Spts.vin.rectif.j aa 5 SS I 16 

Aq. dest. adfgiv; 128 M. 

Sig. Apply morning and evening on a rag. 

Lastly, it should not be forgotten that many cases of intractable 
pruritus are best managed when the attention of the patient is 
diverted from the malady by the distraction incident to travel, aided 
by change of scene and climate. 

Prognosis. — Pruritus senilis is usually an intractable disorder, and, 
when dependent upon senile alteration of the cutaneous tissues, is 
incurable. For all other forms of the disease a prognosis should be 
formulated with reserve. Under the influence of systematic and 
appropriate treatment, the happiest results are often obtained. Other 
cases, especially those associated with hypochondriasis, may bid 
defiance to all remedial measures. Relapse of the local forms of the 
malady, especially of that of the ano-genital region, is sufficiently 
common. In many of these patients the treatment serves merely to 
palliate the disorder, which recurs with every renewal of the cause. 

Pruritus Hiemalis, Prurigo Hyemalis, " Frost-itch " or 
Winter Prurigo. — Under the first title, Duhring 1 described a 
harsh and pruritic condition of the skin, essentially unattended by 
structural alteration, invading all surfaces of the body, but chiefly 



1 T'liila. Med. Times, January 10, 1874. See, also, a later but independent observation by 
Ilutcbinson : I.eeture on Clinical Surgery, 1S78, vol i., pt. 1, p. 100, and Brit. Med, Journ , 1ST."). 
p. 773. 



PRURITUS. 589 

the inner faces of the thighs, the calves of the legs, and the neighbor- 
hood of the joints of the lower extremities, usually occurring in the 
autumn, and continuing until the following spring. It possesses 
many features in common with the forms of pruritus already de- 
scribed, including variability in the subjective sensations awakened, 
nocturnal exacerbation, and the absence of a primary eruption. The 
secondary results are also similar, being sequelae of self-inflicted 
injury in the form of roughness, peri -follicular redness and papula- 
tion, torn and fractured hairs, excoriations, blood-crusts, and, in 
severe cases, an induced dermatitis. It, however, abates in severity 
with a rise of atmospheric temperature, though the author has occa- 
sionally noted persistence of the distress after such weather changes. 
The affection, moreover, is one which occurs in persons otherwise 
enjoying perfect health, in those of every social grade, irrespective of 
the character of the clothing worn and of the habitual use or neglect 
of the bath. It is, without question, a disease of northern climates, 
and more particularly of climates like our own where the variations 
of temperature between the extremes of the summer and of the winter 
range between one hundred and one hundred and twenty-five degrees 
Fahrenheit. The careful description by Duhring presents a picture 
whose accuracy is verified by clinical observation, and which justifies 
the recognition of the disease as a form of cutaneous pruritus. Its 
treatment is that detailed above, the author named laying stress upon 
emollient unguents, glycerine in the form of lotion or ointment, and 
alkaline baths. In my experience, the dusting powders, when em- 
ployed after the tepid bath, have proved more serviceable than any 
fat-containing substances. 

Prairie Itch. — This is a popular term applied largely in the 
Western, Northwestern, and Southern States of this country to a 
cutaneous affection productive of itching sensations. It is supposed 
to be the disorder also popularly described as the "Texas Mange," 
" Ohio ScRxVtches," " Swamp Itch," " Lumberman's Itch," etc. 
A parasitic origin has been claimed for it by several observers, who 
also insist upon its contagious character and its curability by para- 
siticides. 

The personal experience of the author has led to the conviction 
that these terms are loosely applied to a group of cutaneous symptoms 
of diverse origin. The most frequent by far is a pruritus, of the kind 
described above as pruritus hiemalis, occurring in the autumn, 
winter, or spring of the year, and aggravated by the coarse and 
cheaply dyed woollen undergarments of the poor and hard-working 
inhabitants of the lumber camps, mining districts, etc. With these 
causes in full operation, there is often aggravation after swallowing 
drugs for relief of the pruritus based upon the idea of " purifying 
the blood." 

With these cases occur those of undoubted scabies, for the study of 
which the reader is referred to the chapter devoted to that subject. 
The proportion between the purely pruritic and purely parasitic cases 



590 DISEASES OF THE SKIN. 

of this class cannol be definitely determined. It probably differs in 
different places :ui<l seasons, the proportion of cases of scabies increas- 
ing in the lumber camps when they are reinforced by newly arrived 
immigrants infested with acari. It decreases to probably not more 
than from one to two per cent, of all skin diseases in the interior 
villages and towns of the West and Northwest where there has been 
no immigration for some length of time, and where, after the first 
onset of sharply cold weather in the autumn, a large part of the inhab- 
itants suffer from pruritic Bensations in various degrees. 

A review of the somewhat scanty literature on this subject 1 suggests 
the conclusion that the disorder thus popularly designated is far more 
rare in Europe than in America. It is possible that the situation of 
those parts of the United States where this group of skin affections 
seems to prevail (at a great distance from proximity to the sea-shore 
and still further separated from the Gulf Stream) may play an 
important part in the extraordinary sensitiveness of the skin to 
climatic changes. Certain it is that a great number of these affections 
are entirely relieved by removal to a suitable climate, more particu- 
larly to one of the Eastern, Southern, or extreme Western States. 

The therapy of this affection is that of pruritus already described, 
save where a parasite is recognized as the efficient cause, as in cases 
of scabies. 

The prognosis is favorable, though the disease is at times intract- 
able, persisting or recurring with repeated thermometric variations 
till the warm season is at hand. 

[B.] Dermatalgia. 

In this morbid state, the integument becomes the seat of painful 
sensations, which may and may not be associated with a hyperses- 
thetic condition. This disorder is much more frequently symptomatic 
than idiopathic, and partial rather than general, being in the larger 
number of cases a local expression of some disease of the nervous 
centres or tracts. It is observed usually in middle life, and in 
women more than men. Its symptoms vary in severity and in char- 
acter. The pain is differently described as comparable to that pro- 
duced by friction, incision, penetration, contusion, or burning of the 
integument, as also to the passage over the part of streams of very 
hot or cold water, or the electric current. With this there is com- 
monly associated an undue sensitiveness to contact with foreign 
bodies. The skin presents no objective signs of disease. The dis- 
ordered sensations may be limited to the scalp, the region of the 
spine, or the palmar and plantar surfaces. In the latter situation it 
is often significant of some obscurely developed systemic disease, 
such as syphilis, rheumatism, or locomotor ataxia. In a middle- 

i See tun papers by the author, entitled "On the Affections of the Skin, Induced by Temperature 
Variations in c,,M \\Vathrr." Chicago Med. Journ. and Examiner, Mar. h, 1885, and February, 1886; 
Obersteiner : Wien. med. Wuchenschrit't, No. in, 18S4; Brodie : Peninsul. Journ. of Medicine, 1853-54, 
vol. i., p. 506; Jones: Kansas City Medical Index, 188G, with views of several Western physicians; 
Clark : Medical Aw, 1880 ; Payne : British Medical Journal, May 3, 1887. 



ANAESTHESIA. 591 

aged woman, lately under my charge, a persistent dermatalgia of the 
interscapular region was associated with confirmed gastric dyspepsia. 
In other cases the disorder is dependent upon disturbance of the 
uterine function. It is occasionally observed as one of the rare signals 
of the occurrence of the menopause. 

It is to be noted that the severe dermatalgia associated with dis- 
orders of the uterus in women, is occasionally succeeded by a cuta- 
neous lesion. In a middle-aged dysmenorrhoeic patient under my 
charge, a pea-sized hemorrhagic bulla appeared over the forehead 
after several weeks of frontal suffering. Buck, 1 also, reports derma- 
talgia of the brow and wrists in a young woman who had frequently 
miscarried, followed by recurrent formation of a vesicle which 
accomplished its career of rupture, crusting, and erosion, in a stadium 
of from five to seven days. 

The disease is to be differentiated from pruritus and hyperesthesia 
of the skin, as also from the affections of deeper parts, muscular, 
nervous aponeurotic, and visceral. Severe pain, limited strictly to 
the skin of the lumbar region, with hyperesthesia, may precede the 
occurrence of perinephric abscess. 

The treatment is to be directed to the disorder, of which, in the 
great majority of cases, the dermatalgia is merely a local symptom. 
Temporary relief may, however, be afforded by the local application 
of the rubber bag filled with very hot or very cold water ; sometimes 
by an alternation of the two, each for a few moments at a time. 
Sponging of the part with very hot water is also useful, continued 
for longer periods, and followed by swathing in cotton batting 
covered with the Lister protective. The anodynes may also be 
used topically with advantage ; especially cocaine or the oils, com- 
bined with opium, aconite, belladonna, and stramonium. Iu some 
cases relief is had by painting the part with Squibb's oleate of mer- 
cury and morphia, a preparation particularly well adapted to meet 
the indications presented. The skin should generally, in the interval 
of applications, be protected by a dusting powder ; and the clothing 
worn next the skin be of an unirritating character. Care should be 
taken in dermatalgias limited to the trunk of women, lest the corsets 
be responsible for the mischief. The prognosis depends upon the 
nature of the cause of the abnormal sensations. In general it may 
be said that these cases are less persistent and annoying than those 
of confirmed cutaneous pruritus with melancholia. 

Anaesthesia. 

Gr. a, privitive ; aia&vcrig, sensibility. 

In this condition there is [total or partial diminution of sensi- 
bility, with and without structural alteration of the skin. As in the 
affection just described, the disorder may be either idiopathic or 
symptomatic, general or partial, unilateral or bilateral, central or 
peripheral, and in varying grades of severity. Illustrations of the 

1 Pliila. Med. and Surg. Reporter, Jan. 18, 18SI, p. 677. 



592 DISEASES OF THE SKIN. 

disease are furnished in the anaesthetic patches of leprosy, which may 
and may not exhibit textural skin changes, the disorder resulting 
from involvement of the nerves. < >ther diseases and conditions may 
be accompanied by partial or total 1<hs of cutaneous sensibility, 
including centric and eccentric paralyses; syphilitic, hysterical, and 
ataxic disorders ; partial or complete anaesthesia of artificial produc- 
tion ; the several toxic na reuses ; traumatism of nerves by pressure, 
wound, or contusion ; the local anaesthesias induced by cold, frigorific 
mixtures and substances capable of benumbing the sensitiveness of 
the skin; coma, of whatever origin; and a number of idiopathic 
cutaneous disorders, including certain of the atrophies, scleroderma, 
and morphoea. 

A curious divorce occasionally obtains between the elements which 
together constitute the compound sensory impression derived from 
the touch. The recognition of pain, of degrees of temperature, as 
also of the form, size, density, distance, weight, resistance, and other 
properties of foreign bodies, is accomplished largely by the sensory 
nerves : and the power to appreciate one or several of these objective 
qualities may be in different degrees impaired. In this respect 
several forms of what, for want of a better term, may be named 
cutaneous anaesthesia, are comparable to the conditions recognized in 
color-blindness. Thus, in some cases, there is appreciation of heat, 
but not of cold ; of form, and not of weight ; of pain, and not of 
objective qualities ; and the reverse. A curious illustration of this 
occurred in the person of a leper under my observation, whose hands 
were in all parts quite sensitive to the prick of a lancet and to contact 
with heated substances ; who yet exposed them for hours, without 
protection, to an atmospheric temperature of ten degrees below zero, 
without becoming aware of even slight discomfort. 

The neuroses described above are those of sensibility. Unques- 
tionably there are, beside these, a number of cutaneous affections 
popularly termed neuroses, which require mention in this connection. 
Unfortunately, in the present state of science, it is not certainly 
determined to what special class these affections should be definitely 
and permanently assigned. Some of them have already been 
described in these pages. In what follows there is attempted a 
schematic classification of the symptoms displayed in all, without 
attempting to discriminate between the parts severally played in each 
by nerve, vessel, and tissue. 

Vase-motor and Trophic Neuroses. 

Under the first of these titles, Schwimmer discusses erythema mul- 
tiforme, herpes iris, erythema nodosum, urticaria, and the medicinal 
ervthemata ; under the second, prurigo and herpes (simplex and 
zoster). 

It is, however, to phenomena of a different character that in these 
pages attention is directed by these terms. These symptoms are, for 
the most part, Symmetrical in distribution, aud largely limited to the 



NEUROSES. 593 

hands and feet, though in some instances, with or without implica- 
tion of these orgaus, other parts are invaded, most often the mouth, 
next the scalp, lastly the trunk. The four groups named below are 
readily recognized. 

In the first group the symptoms are functional chiefly, invading 
the feet alone, or the hands alone, or both the hands and feet, the 
symptoms predominating either in the one or the other. These are 
symmetrical hyperidrosis, anidrosis, bromidrosis ; coldness of the 
organs, and symmetrical asphyxia ("dying" of the hands or feet, 
when immersed in cold water, digiti mortui). With the local phe- 
nomena may occur sudden attacks of faintness or giddiness; a pulse 
ranging from very slow to very rapid action, and rheumatoid pains. 
Many of these symptoms are associated with those next described. 

In a second and larger group may be collected the symmetrical 
structural changes in the skin and its appendages without destructive 
degeneration, cutaneous or subcutaneous in situation. With these 
may be associated the blueness, coldness, or wetness of the organs, 
referred to above. One or several, usually all, of the nails may be 
here involved, these appendages becoming rough, dry, lustreless, 
friable, or gryphotic. They are usually tilted away anteriorly from 
their nail-beds by a corneous deposit visible beneath the free border. 
Here, also, may be enumerated, symmetrically arranged, livid or 
reddish blotches; erythematous, vesicular, and scaling patches; local- 
ized hypertrichoses and alopecias [of the legs chiefly]; tyloses of 
palms and soles [in cases, with recurrent slough of the callosity] ; and 
local anaesthesias. 

To this group belong the Neurotic Excoriations of Sir Erasmus 
Wilson, 1 an example of which was shown at the International Med- 
ical Congress of London. The Bleeding Stigmata which attracted 
the attention of the French and Belgian authorities in the years 
1873-1875 belong to the same category, as also the "Glossy Fingers" 
of Paget [q. v.]. 

In a third group may be placed the phenomena of Raynaud's 
disease, the cases of symmetrical ulceration and gangrene, and the 
other ulcerative and degenerating lesions, not necessarily fatal, in- 
cluding the "perforating ulcer of the foot" [malum perforans pedis] 
[q. v.]. Here are classed the cases described by Atkinson as "mul- 
tiple cutaneous ulceration," and the well-known cases of Eichoff, 
Boeck, Simon, Weiss, and Hutchinson. 

Leloir and Dejerine presented a case of this character at a recent 
meeting of the Societe de Biologie, in Paris. A young girl, of a 
family, several members of which were affected with nervous diseases, 
had, without any apparent cause, several patches of superficial gan- 
grene developed on the cheeks; the small eschars soon separated, 
leaving a linear cicatrix, which gradually became transformed into 
cheloid elevations. The first happened three years before, and during 
this period she had suffered from several similar lesions on the trunk 

1 Lectures on Dermatology. Loudon, 1875. p. 192. 



594 DISEASES OF THE SKIX. 

and arms. They began on the skin, by a sensation of pricking, 

with slight redness and notable diminution of sensibility at this 
point; in nine hours a white patch, not preceded by phfyetcnnlfe, 
formed and underwent, after a short time, superficial gangrene. 
Later the spot became brownish, detached at the edges, and was 
finally eliminated, Leaving an ulceration and a cicatrix, the anaesthesia 
which existed around the pari finally disappearing. 

In a fourth and final group may be set the cases which end fatally, 
in consequence of an apparently lethal tendency of the disease from 
the first Here may be cited Hutchinson's "Form of Inflammation 
of the Laps and Mouth, which sometimes ends Fatally, and is usually 
attended by some 1 disease of the Skin;" and a list of affections with 
cutaneous symptoms chiefly studied by neurologists, including the 
u !>ir<I tabitique" of Charcot; cases of posterior spinal sclerosis, and 
cases of syphilitic, tuberculous, and rheumatic disease of the cord and 
meninges. 1 

The pathology of many of these disorders is clear, changes in the 
central and peripheral nervous tracts having been found sufficient to 
account for the phenomena (absence of axis-cylinder; thickening of 
neurilemma; increase of endoneurium). In other cases, no lesions of 
the nerves have been recognized, and authors have not been wauting 
who regarded some of the disorders named above as "purely local" 
in character. 

The subjoined bibliography is appended in view of the uncertainty 
respecting the proper distinction to be established with respect to 
several of the disorders named above: 

Atkinson. Amer. Journ. Med. Sciences, 1884, p. 57. 

Atkix, Charles. British Med. Journal, July 24, 1886. 

AlTDEHSOK, McCALL. Treatise on Diseases of Skin. London, 1887. 

Baker, Morraxt. Clin. Soc. Trans., vol. xviii. 

Bouchard. Gaz. des Hopit., No. 112, 1884. 

Boeck, Cesar. Viertelj. f. Derm. u. Syph., 1881. 

Ball and Thibierge. Lancet, Oct. 21, 1882. Eeportto Int. Med. Congress. 

Brehier. These de Paris, 1874. 

Biggs. Lancet, 1876, vol. vii. p. 735". 

Billroth. Wien. ined. Wochen., No. 23, 1878. 

Collander. Clinical Society's Trans., April 12, 1878. 

Duplay. Arch. gen. de Med., 1876, p. 346. 

Dejerine. Le Progres Med., 1882, No. 6. 

et Leloir. Arch. gen. de Phys., 1881, p. 1011. 

Eichoff. Deutseh. med. Woch., No. 34, 1880. 

Elliot. Journ. of Cutan. and Gen.-Ur. Dis., May and June, 1887. 

Erichsex. Surgery, 1879. 

Estlaxder. Arch. f. klin. Chir., 1870, xii. p. 453. 

Flyxx. N. Y. Med. Record. March 28, 1S85. 

FOUTXJUTER. These de Paris, 1N74. 

Hamilton*, A. M( Lane. N. Y. Med. Journ.. Oct. 1874. 

Hastreiter. Wiener med. Presse, 1882, No. 33. 

Hutchixsox, J. British Med. Journ., June 18, 1887. 

British Med. Journ., May 7, 1887. 

Heusxer. Deutseh. med. Woch., No. 16, 1885. 

i See the author's paper on "Symmetrical Hand and Foot Disease," nad lefore'the American 
Dermatological Association, August 31, U>87. 



MYXCBDEMA. 595 

Jones, S. Path. Soc. Trans., No. 7, 1876. 

Kirmisson. Arch. gen. de Med., January, 1885. 

Michattd. Lyon Med., January, 1876. 

Miles. Amer. Journ. of the Med. Sci., October, 1878. 

Mitchell. Amer. Journ. of the Med. Sci., July, 1878. 

Mougeot. These de Paris, 1867. 

Nelaton. Gaz. des. Hopit., January 10, 1852. 

Ogstojst. Lancet, 1878, p. 13. 

Pitres et Vaillard. Arch, de Phys., Feb. 15, 1885, p. 209. 

Petit et Verneuil. Eev. de Chirurg., No. 19, 1883. 

Baynaud. Arch. gen. de Paris, 1874. 

These de Paris, No. 28, 1862. 

Simon, Oscar. Breslau Arzlische Zeitschft., No. 1, 1879. 

Schwimmer. Art. Malum perforans Pedis— Ziemssen's Handbook of Diseases 

of Skin. 
Savory and Butlin. Med.-Chir. Trans., vol. lxii., 1879 (illustrated). 
Starr. Journ. of Nervous and Mental Dis., February, 1886. 
Terillon. Bevue Medic, 1886. Beport made to the Surgical Society of 

Paris. 
Tilden. Journ. of Cutan. and Vener. Dis., October, 1886. 
Treves, Frederick. Lancet, March 29, 1884, p. 950. 
Warren. Boston Med. and Surg. Journ., No. 13, 1879. 
Weiss. Wiener Klinik, 1878. 
Wilks. Surgery of the Foot, p. 57. 

Myxoedema. 

Gr. fiiil-a, humor ; bideu, to swell, 

Myxoedema is a disease characterized by a constitutional cachexia, which 
usually results in the production of a cretinoid state, and is accompanied 
by a characteristic pachydermia. 

This disorder was first described by Sir Win. Gull, 1 in 1873; and 
it has since been often observed, both abroad and in this country, by 
competent observers, including Orel, 2 Mahomed, 3 Hadden, 4 Stokes, 5 
Hammond, Horsley, and Ballet. It is termed by the French 
"" Cachexie Pachydermique." For thirteen cases reported in, this 
country, the reader is referred to an interesting report by Dr. A. B. 
Ball, of New York. 6 

Symptoms. — The disease occurs in both acute and chronic mani- 
festations, usually after the fortieth year, and in women more often 
than in men. It may, however, be first noticed in childhood. 

There is first observed a persistent and remediless anaemia, gradu- 
ally succeeded by mental hebetude, sluggishness of bodily movements, 
and the characteristic change in the skin. The latter becomes dry, 
waxy, translucent, thickened, firm, and refuses to pit on moderate 
pressure, the mucous membranes often participating in the morbid 
process. In the cheeks there is usually perceptible a brawny redness ; 
defined at times as a sharply circumscribed pinkish flush extending 
quite to the lower lids, which may be, as in Ball's cases, wrinkled, 
boggy, and swollen. The eyes, for this reason, seem smaller than 

i Trans. Clin. Soo. London, 1874, vii. p. 170. 2 Med. Chir. Trans., 1878, v. p. 57. 

3 London Lancet, 1881. ■* Brain, 1882, 4. 

5 N. Y. Med. Record, July 10, 1886. « British Med. Journ., Oct. 16, 1886. 



596 DISEASES OF THE SKIN. 

natural and more widely separated. In consequence of the swelling 
and immobility of the features, the facies is characteristic: the broad, 
thick nose; Swollen, pendulous, or even everted lips; expressionless 
eyes; and leathery cheeks producing a mask-like impression upon 
the observer. The skin of the other regions of the body participates 
in these changes. 

In the triangles at the side of the neck, and also at its back, are 
" bolsters" of fat. The hair of the head becomes harsh and scanty ; 
alopecia may be complete. Pigment alterations readily occur ; moles 
increase in size; and the general tint of the skin may vary from that 
of dry parchment to the hue of Addison's disease. The gait is 
waddling and uncertain. The thyroid gland atrophies. Anesthesia 
is of common occurrence. The tongue, uvula, and fauces are often 
so thickened and immobile as to make the speech both slow and 
indistinct. 

Stokes reports ten cases of acute myxcedema following thyroid- 
ectomy. In these cases, beside the rapid occurrence of the symptoms 
enumerated above, there were convulsive seizures of an epileptiform 
character. 

Etiology. — The cause of this disease is imperfectly understood, 
though its association with the abolition of the thyroid gland (after 
pathological change or ablation) is generally admitted. The influence 
of heredity is distinctly shown in cases reported by Ball, Ord, Saville, 
and Taylor. One hundred and one, of one hundred and twenty-one 
cases collected by Ball, occurred in women. The disease may affect 
children, but is more common in middle life. 

Pathology. — The disease seems to be due to the deposit of mucin, 
or "animal gum," in the meshes of the connective tissue. This 
mucinoid degeneration may involve the pueumogastric, glosso- 
pharyngeal, great sympathetic, and other nerves. " The psycho- 
cortical centres are unquestionably similarly involved. In the "skin, 
the fibrillae of connective tissue multiply, their nuclei becoming large 
and distinct. The mucin-yielding cement substance between these 
fibrillae appears in large amounts in the interstitial spaces. In a 
post-mortem examination made by Ord, it was estimated that the 
skin contained fifty times the normal amount of mucin. 



CLASS VIII. 

PARASITIC AFFECTIONS. 

The cutaneous disorders of this class possess many features in 
common with those already described. In them, as in others, are 
observed the hypersemic and exudative processes which result in 
surface lesions of similar type and career. They differ, however 



TINEA FAVOSA. 597 

from other affections of the integument, in that they are all induced 
by parasites of either vegetable or animal origin ; and are, as a con- 
sequence, commonly characterized by certain special features. They 
involve the skin and its appendages, their symptoms being at times 
displayed chiefly in the integument proper, and at others in one or 
more of the cutaneous appendages, according to the mode of propa- 
gation and attack, peculiar in each case to the parasite present. They 
are all in different- degrees contagious ; and being induced by local 
and tangible causes, are usually readily relieved by external treat- 
ment. Their importance in cutaneous medicine rests not only upon 
the facts named above, but also upon the too general misconception 
regarding their nature, since there are many patients treated by 
internal remedies ingested vainly for long periods of time, who are 
yet suffering from parasitic disorders often remediable by very simple 
local measures. 

It should not be forgotten, however, that, distinct though these 
maladies be in an etiological sense, they are yet practically often 
commingled with others. Thus an eczematous scalp in a child may 
by accident become the habitat of lice ; and the eczema induced 
originally by the acarus scabiei may long persist after the destruction 
of the parasite. 

The term tinea, derived from a Latin word meaning a moth or 
worm, has by common consent been adopted as a generic designation 
of all the cutaneous disorders induced by the presence of vegetable 
organisms. 

1. Vegetable. 

Tinea Favosa. 

Lat./avws, a honeycomb. 

Tinea Favosa is a contagious disease of the scalp, and less frequently of other 
portions of the surface of the body, characterized by pea- to coin-sized, 
sulphur-yellow, and umbilicated crusts commonly traversed by hairs, and 
produced by the invasion of a vegetable organism, the achorion Schon- 
leinii. 



ims. — Favus affects chiefly the scalp, but also occurs upon 
the so-called non-hairy portions of the skin and the nails. In the 
former situation it is usually first recognized by the development of 
minute, sub-epidermic, yellowish or reddish puncta, visible through 
the translucent stratum corneum at the site of implantation of the 
hairs. A peripheral circle of delicate vesicles may surround these 
spots. Puncture with a needle usually gives exit to a puriform 
matter. In the course of a fortnight or more, these develop into 
pea-sized and somewhat larger, friable, circular, and elevated crusts, 
having the yellowish tinge of the lemon or sulphur, and a concavo- 
convex shape, with the free concave face of the disk exposed. At 



598 DISEASES OF THE SKIN. 

the centre of the umbilication thus presented to the eye, one or 
several hairs usually make exit to the surface. The inferior surface 
of this disk or seutuluin rests upon the scalp, which is either moist 
and deprived over a circumscribed area of its epidermis or is smooth, 
dry, reddened, and tender. When the crust is removed by traction 
upon the hairs or otherwise, a minute cup-shaped depression is left 
at the point where the lowest level of the favus crust was in intimate 
connection with the epidermis. 

The subsequent features of the crusts, the hairs, and the seal]), are 
subject to some variation. The first may acquire a brownish or 
greenish tinge by admixture with dirt or dried pus ; may coalesce 
(favus squamosus), or may, by gradual desiccation, exchange the 
yellowish hue for the dirty whitish shade of old mortar, a substance 
which they then resemble in dryness and friability. The hairs, 
invaded both in sheath and shaft, may lose their lustre; become 
fragile; appear as fractured relics of longer filaments; be readily 
extracted from their follicles ; and be finally shed, leaving behind, 
hair-sacs destined to fall into atrophy, and incapable of reproducing 
a pilary growth. The scalp may he first the seat of an extensive 
hyperemia or exudation going on to the formation of pus, when the 
organism is a source of acute irritation in consequence of its active 
development. Later, when its destructive work may be said to have 
been accomplished, the scalp surface is bald, irregularly atrophied, or 
disfigured with minute cicatrices, while here and there remain tufts 
of hair which have survived the attack. 

The lesions may be discrete or confluent, aud vary in either case. 
Occasionally but a few small and ill-developed crusts form upon the 
surface. The entire scalp is not often covered with a confluent favus 
crust. The disease is usually chronic in its course. Untreated, it 
may undergo spontaneous involution after total destruction of all 
hairs and production of general follicular atrophy, but this is rare. 
It may last for fifteen or twenty years, and even longer. It is often 
accompanied by adenopathy. 

The disease usually awakens a noteworthy degree of itching ; and, 
as a result, it is not rare to find the favus crusts torn and broken by 
the comb or the nails. 

The yellowish disks of the disease occur also in typical develop- 
ment, though more rarely, upon the surface of the face (including the 
bearded cheeks, lips, and chin), and upon the trunk and extremities. 
Dr. George Henry Fox, of New York, has photographed a patient's 
knee which is covered on its extensor aspect with favus crusts. 

When the nails are invaded, light or deep yellowish, circumscribed 
spots become visible through the nail structure, and by the extension 
•of these, in consequence of the growth of the parasite, the nail-tissue 
may be thickened, irregularly split, laminated, separated from its 
matrix, or atrophied. The complication is rare, and supposed to be 
due to the transfer of the organism from the scalp to the hands in the 
act of scratching. When it exists, the epidermis fringing the nail is 
usually also involved. 



TINEA FAVOSA. 599 

The odor of fully developed favus is so characteristic that by it 
alone a diagnosis has been established. It is usually compared to the 
odor of mice ; also to that of the urine of cats. It should not be 
confounded with the peculiarly disgusting odor of many neglected 
scalps affected with lice or covered with pustules and filth. The 
disease not infrequently coexists with other cutaneous, parasitic, and 
non-parasitic diseases : as, for example, seborrhoea, eczema, and tinea 
tonsurans. 

Etiology. — Favus is always produced by the presence and develop- 
ment of the vegetable organism which is named after its discoverer, 
the achorion Schdnleinii. It is a contagious disease, simply because 
the parasite which produces it, is capable of transmission from man to 
man, as also from animals to man, and vice versa. It shares with 
other diseases originating from vegetable parasites, the peculiarity of 
attacking certain individuals specially predisposed to the invasion, 
either by physical peculiarities of organization, or accidental and 
fortuitous circumstances. It is most common from infancy to the 
thirtieth year of life. It is rare in the United States, Austria, and 
England ; and more common in France, Scotland, and Poland. It 
is said by Bergeron 1 to be a disease of the country, while tinea tri- 
chophytina prevails in the cities. This statement is certainly corrob- 
orated by the author's experience. Favus is more common in public 
than in private practice, and the larger number of clinical patients 
with favus come to the city from the country. 

Evidences of contagion are exhibited in those cases where several 
members of the same household are aifected with the disease ; but in 
other cases the absence of a history of contagion after exposure indi- 
cates the relative difficulty experienced in propagating the contagious 
element in the case of favus. Thus one individual, exposed among 
a dozen who are diseased, will fail to exhibit any favus crusts ; and 
the latter by no means form in all situations of the same body where 
the fungus can be discovered by the microscope. Aubert, 2 indeed, 
presents an argument in favor of the production of the disease by 
traumatism, the resulting wounds, excoriations, etc., becoming by 
accident the seat of the disease. 

Occasionally favus occurs in special localities with such develop- 
ment among men and the inferior animals as to constitute an 
epidemic. Girard 3 reports thus the simultaneous existence of the 
disease among sixteen cows and four children in the village of 
Nantoin, in France. It is propagated also upon the skin of rats and 
mice, from which it is transmitted to man, often through the medium 
of the domesticated cat and dog. 

Pathology. — Under the microscope, the fungus is readily recognized 
in the root-sheaths, the bulbs, and the shafts of the hairy filaments 
near the scalp. At a distance of about two inches from the bulb it 
ceases to appear in the tissue of the hair. It is also seen upon the 

1 Etude sur la Geographie et la Prophylaxis des teignes, Paris, 1865. 

2 Role de traumatism dans l'etiologie de la teigne faveuse (Annal. de Derm, et de Syph., April, 1881). 
a Lyon Med., August 18, 1880, p. 547. 



600 



DISEASES OF THE SKIN. 



free surface of the skin. The favus crust, softened by the addition 
of a little water or dilute liquor potassse, may be placed upon the 
slide of the microscope without other preparation for it- study. 
Under a good one-fourth or one-sixth of an inch objective, the vege- 
tation is seen to be composed of intricate masses of mycelium and 
spore.- in gnat quantity. 

Fig. 79. 




Achorion Schiinleinii. a, spores ; 6, c, sporophores. (After Cornil and Ran vier.) 

The former usually preponderate, and appear as narrow, flattened, 
ramifying, short or elongated, thread-like cells or tubes. These may 
be simple and empty, or be divided more or less regularly by trans- 
verse partition walls, transforming the longer and simple into shorter 
and compound cells. The latter often contain in their cavities spor- 
ules clinging to either side, in which case the mycelial threads are 
termed sporophores. This is the vegetative part of the cryptogamous 
fungus ; and it develops by multiple subdivision into cells, which may 
also themselves similarly increase in number, or by the production, 
at the terminal extremities of certain of the mycelial threads, of spores 
or couidia. The latter are encapsulated, or strung together like the 
beads upon a necklace, and appear as round, oval-shaped, angular, 
or very irregularly contoured bodies, often provided with partition 
walls like the mycelia, constituting thus compound cells. At the 
same time, an amorphous granular matter can usually be distinguished 
in the mass of the fungus According to Duhring, who has made 
careful measurement of these elements, the mycelia vary in width from 
0.0023 to 0.0030 mm. ; and the spores, from 0.0023 to 0.0052 mm. 

Examination of the invaded scalp reveals, according to Uuna, 1 the 
presence of the fungus at the lower border of the upper three-fourths 
of the root-sheaths, where chains of conidia appear among the histo- 
logical elements. His view is that the cuticle of the hair offers a 
relative resistance to the growth of the vegetation ; that the latter 
first penetrates the stratum corneum and the follicular orifice, and 



Viertelj f. Derm. n. Sypta., vii. p 170. 



TINEA FAVOSA. 601 

then stretches, upon the one hand, into the cortex and medulla, 
through the cuticle of the hair; and, on the other, passes to the inner 
root-sheaths, the outer remaining always intact. In the epidermis, 
the fungus has a predilection for the tissues between the superficial 
and deep portions of the stratum corneum, stopping as if before a 
wall, at the living protoplasmic masses of the rete. The superior 
pars vascularis of the corium exhibits enlarged vessels surrounded by 
inflammatory elements. 

When the nail is involved, the parasite may be recognized in the 
debris produced by scraping the nail-substance; often also in the 
epidermis bordering the nail. It exhibits here the same microscopical 
features as upon the scalp, though in consequence of the denser 
structure of the nail-substance, its vegetation is usually less luxuriant. 

Diagnosis. — The clinical recognition of favus is based upon the 
presence of the characteristic, yellowish, cup-shaped crusts, often aided 
by a history of contagion, and the peculiar odor emanating from the 
scalp. The secondary effects upon the hairs, hair-follicles, and skin, 
are also, when present, significant. Dr. White, of Boston, in a valu- 
able essay on the "Vegetable Parasites, and the Diseases caused by 
their Growth upon Man," calls attention to the stage in which the 
disease is likely to be mistaken for ringworm. It exists before the 
formation of the crust, and may be characterized by hyperemia, 
vesiculation, or papulation, often unnoticed beneath the hairs of the 
scalp. 

The recognition of the disease by the microscope is, however, the 
most certain method of establishing a diagnosis ; and this is readily 
accomplished. Aubert, 1 in the absence of the clinical features named 
above, lays stress upon an intense redness of the scalp where the hairs 
have been cut and the crusts removed, this color being limited to the 
portions attacked by the disease. The hairs, also, as a result of the 
disintegration of their elements, are infiltrated by air, and look 
opaque and black by transmitted light. By reflected light, these 
appear polished and stratified. It should not be forgotten that, in 
exceptional cases, favus crusts coexist upon the body with other 
diseases of prior or subsequent origin, as indicated above. The dis- 
ease should not be confounded with seborrhoea, pustular eczema, or 
psoriasis of the scalp, none of which exhibits the special features of a 
parasitic fungus. 

Treatment. — The first indication in the treatment of favus is to 
cleanse the surface thoroughly from all favus and other crusts and 
scales which may be present. For this purpose the scalp (if this be, 
for example, the affected part) is first shorn of its hair with the 
scissors, and then thoroughly soaked in olive, cod-liver, or other oil, 
or glycerine. After this, all the crusts are scraped away with a spa- 
tula, and the scalp washed clean with hot water and soap, the spirit 
of green soap being here preferably used. The scalp should be then 
again anointed with oil, or covered with an emollient poultice. Once 

1 Annal. de Derm, et de Syph , 2m. ser., 11, p. 34. 



602 DISEASES OF THE SKIX. 

thoroughly cleansed by repeated soakings in oil and ablutions, it is 
necessary to resort either to the topical employment of parasiticides 
(agents capable of destroying the fungus) or epilation (the extraction 
of the hairs). Often both measures are required. Without further 
treatment, the scalp, however completely freed from all evidences of 
the disease, will not tail to show fresh favus crusts in a fortnight or 
somewhat longer time. 

Epilation is practised by the aid of epilating forceps. These 
should be constructed with an easy spring that will not tire the 
fingers of the operator; with blades that are sufficiently broad to 
grasp a few hairs at once; and with smooth, or slightly serrated faces 
of the blade.-, as otherwise the hair is liable to fracture in the grasp of 
the instrument. The surface to be operated upon should be pre- 
viously anointed with vaseline or olive oil, and the hairs be entirely 
removed, a sufficient number, covering a definite space, upon suc- 
cessive days. 

The tediousness of this process has led to several devices by which 
it is sought to do away with its necessity. Originally the "calotte" 
was employed for the removal of the hairs. It was made by smearing 
a disk of leather with pitch, and applying it over the scalp. When 
the calotte was subsequently removed by a brisk motion of the hand, 
the hairs which adhered were forcibly uprooted en masse; those 
remaining being adherent in their sacs in consequence of the fact 
that they had not been invaded by the fungus. As a substitute for 
this somewhat brutal procedure, Bulkley 1 has employed adhesive 
masses, or sticks, which can be melted and made to adhere at once 
to large numbers of the hairs. "When cold they can be withdrawn 
from the surface with the hairs attached. These sticks are from two 
to three inches in length, and from one-fourth to three-fourths of an 
inch in diameter. The hair is first clipped so as to be about one- 
eighth of an inch in length. The end of the stick is then heated in 
an alcoholic flame, and quickly pressed upon the scalp. It is thus 
left in place till quite cold, and removed by bending it over and 
drawing upon the hairs successively with slight rotation. When 
free, it is found thickly set with the extracted filaments, which may 
be burned off in the alcohol flame, thus destroying both the hairs 
and any adherent fungous masses. The stick is then carefully wiped 
clean with paper, after which it is again ready for use. The formula 
for the mass of which these sticks are composed is as follows : 

R. Cerae flavse oiij ; 12 

Laccse in tubulis 3iv ; 16 

Resinie ovj ; 24 

Picis Bur£iindic£e gxj; 4 + 

Gummi dammar. sjss; 48 M. 



The parasiticides in greatest favor are, corrosive sublimate in solu- 
tion in the strength of one-half to four grains (0.033-0.266) to the 
ounce (32.); sulphite of sodium in saturated solution; pure or diluted 

1 Favus and its Treatment by a New Ilethod of Depilation, Arch, of Derm., vii. No. 2, April, 1881. 



TINEA TRICHOPHYTINA. 603 

sulphurous acid; spirit of green soap; tar, croton oil, carbolic and 
salicylic acids ; petroleum, chloroform, ether, creasote, aud the oil of 
cloves. Ointments are also useful containing mercury (citrine oint- 
ment, yellow sulphate or white precipitate), naphthol, benzol, thymol, 
sulphur, salicyl, pyrogallol, and carbolic acid. Chrysarobin is very 
effectual in an ointment, though objectionable on account of the 
staining of the scalp, and, almost inevitably, of the face also. Lenz- 
berg 1 generates sulphur fumes in a dish of red-hot coals attached to a 
frame, made of wood or paste-board, close to the head of the patient. 
By means of a paper cap, the fumes are collected and retained for 
from five to ten minutes, in contact with the patient's hair. During 
ten years' trial of this plan, he has never been compelled to resort to 
epilation. 

One or more of the methods may be needed, either at the same 
time or by repetition or alteration, till the fungus is entirely destroyed, 
the requisite period usually extending over three months. Treat- 
ment should then be discontinued, in order to test the result by obser- 
vation. If, in the course of a fortnight or more, a relapse occurs, 
the treatment is to be promptly renewed. Upon the non-hairy por- 
tions of the body, parasiticides thoroughly applied usually procure a 
radical relief. When the nail is involved, it should be cut short and 
carefully scraped or softened by repeated applications of a strongly 
alkaline lotion, after which a parasiticide may be employed in oint- 
ment or lotion. 

In general, it may be remarked that patients long affected with 
rebellious favus, may need a roborant course of treatment and nutri- 
tious diet. Cleanliness here, as in all the parasitic disorders, is 
essentially important. As adjuvants in the treatment of the scalp 
and nails, it is well to remember that continuous applications of a 
parasiticide are aided by caps or cots of impermeable material, super- 
imposed upon rags saturated with the medicament employed. 

Prognosis. — The prognosis is generally favorable to the ultimate 
termination of the disease in all cases ; for even the most rebellious 
and untreated forms are relieved when the hair follicles atrophy. 
Upon the non-hairy portions of the body, the disorder is rarely 
severe if promptly and efficiently treated. Upon the scalp, the prog- 
nosis is proportioned to the extent, severity, and period of prior 
invasion of the disease. Early and vigorous treatment of the scalp 
in healthy children, is usually followed by satisfactory results. Neg- 
lect, filth, and systemic malnutrition, are the most unfavorable 
elements in any case. 

Tinea Trichophytina. 

Gr. dpi£j } hair ; <j>vt6v } a vegetation. 

Ringworm is a disease of the hairs and hair-follicles of the scalp 
and beard, as also of the non-hairy portions of the body. In each 

1 Der. prakt. arzt., Feb. 1881. 



60-i DISEASES OF THE SKIN. 

case it is produced by the presence of the same vegetable fungus, the 
trichophyton. Inasmuch, however, as each of these regions of the 
body, when the parasite is present, display.- lesions which are more 
or less peculiar to itself, it is usual to consider each separately. Ring- 
worm of the body is hence designated, Tinea Circtnata ; of the 
scalp, Tinea Tonsurans ; of the beard, Tinea Sycosis. 



[A.] Tinea Circinata. 

Tinea Circinata is a contagious disease of the skin, characterized by macular 
vesicular, papular, squamous, and rarely pustular lesions, having usually 
a clearly defined, circular outline, and induced by the presence of the tri- 
chophyton. 

Symptoms. — Ringworm of the body displays different symptoms, 
according to the temperature in which the vegetation flourishes, and 
the various external irritants to which the skin, where it has once 
been implanted, is subjected. 

The macular form of the disease is characterized by the occurrence 
of one or several pea- to large coin-sized, circumscribed, reddish cir- 
cles, usually paling under pressure, often at the general level of the 
integument, occasionally slightly raised above it, forming then a flat- 
tened disk. The centre of the circle may be paler, or indeed to the 
naked eye quite unaffected, transforming the patch to an annular 
lesion, from which circumstance it originally received the name " ring- 
worrn." It develops within certain limits, rarely exceeding five or 
six inches in diameter, by peripheral extension ; and is usually charac- 
terized at the outer border by slight, whitish, furfuraceous desquama- 
tion. This form of lesion is usually seen upon exposed surfaces of 
the body where there is less heat, moisture, and friction, than upon 
others, as, for example, the forehead and neck in moderate atmos- 
pheric temperatures. From it may be developed the other forms 
described below. The disease may recur within the peripheral 
border; in this way occasionally two, three, and more concentric rings 
or parallel bands of crescentic outline may be visible in a single patch 
of disease. The subjective sensations are a trifling degree of itching 
or burning. Should these rings extend to the beard or scalp, the 
cireinate may coexist with the other varieties of the disease. 

The vesicular lesions of ringworm appear as such at the onset, or 
ri-e from the macular lesions described above. In the former case, 
pin-point sized, transitory, and superficial vesicles or vesico-papules 
spring from a central point or focus, or speedily shrivel till they are 
represented merely by minute, whitish, branny scales. To these 
others succeed, always at the periphery, and to these again yet others, 
the rosy or reddened base on which they rest being sometimes 
slightly in advance toward the outlying skin. The enlarging circlets 
of disease proceed in their course to an evolution quite similar to 
that observed in the macular forms. The difference, due chiefly to a 
somewhat more active development of the fungus, is noted not merely 



TINEA TRICHOPHYTINA. 605 

in the type of the lesion, but in the slightly exaggerated pruritic 
sensations which are awakened. Rarely, both of the forms described 
are presented with acute symptoms and extensive development, in 
multiple patches spreading over the face, neck, trunk, and extremi- 
ties, accompanied by a slight febrile movement and moderate tume- 
faction of the affected surfaces. As a rule, the eruption is trifling ; 
and may, indeed, be limited to a single ring, or very few circlets 
about the neck, terminating in the branny desquamation described • 
but in the severer forms the evolution of the disease may persist for 
months, and crusts form, whose fall leaves annular pigmentations of 
temporary duration. 

The papular and rare pustular forms of the disease observe the 
same peculiarities with respect to the clearing of the centre, the 
annular appearance of the advancing area of involvement, and the 
production finally of scales and crusts. They represent, however, 
either a much more luxuriant vegetation of the fungus, or the irrita- 
tion of the affected part by friction and heat, or, what is probable, 
the cooperation of the two. They are, hence, most commonly 
observed upon the back, the belly, the inter- and infra-mammary 
regions, and the internal faces of the thighs and arms, in which 
localities they occasionally occur with chronic manifestations. The 
papules are light or dull reddish, pin-head and larger, solid elevations, 
roundish, oval-shaped, irregular, or confluent, forming eventually 
bean to coin-sized, raised disks with a pale, exfoliating, or actively 
inflamed centre, the so-called "nummular" or " discoid trichophytic 
erythema" of French authors. The itching is sometimes in these 
forms severe • and the process may display central recrudescence, as 
noted above. Pustules found at the periphery have the size and 
distribution of the other lesions described. They represent merely 
an aggravated exudative process awakened by the fungus, and the 
scratching incident to the pruritic sensations excited. 

Partly because of the controversy which the subject has aroused, 
special attention has been directed for some years to the disease which 
Hebra was first to name, Eczema Marginatum. It is most 
marked upon the portions of the body which come in contact with 
the saddle when a rider is mounted on a horse — that is, the perineum 
and the inner faces of the thighs, the region well marked by the 
reinforcing patch in the trowsers of the cavalryman. The disease, 
as encountered here, is termed Tinea Trichopiiytina Cruris, 
and occurs in both sexes. It is characterized by extensive exuda- 
tion, in bright or lurid patches, with a very distinctly defined, raised 
border, showing a sharp contrast with the healthy skin beyond, 
from which peculiarity it has its name. It may extend laterally 
over the groins, upward over the pubes, and backward over the 
sacrum, being generally denned at the periphery by a crescentic 
outline. The centre may be paler and less involved, or actively 
irritated, while the periphery still extends in one or more annular 
festoons down the inside of the thigh or upward over the regions 
indicated. The itching is severe ; the course of the disease obstinate, 



606 DISEASES OF THE SKIN". 

persistent, and subject, in a remarkable degree, to relapse in the same 
Locality. The fungus is always present, whether occurring as a cause 
or epiphenomenon of the disorder. It was rightly named by Hebra ; 
and deserves special recognition under whatever title it be classified. 
It is a true eczema, with special features, complicated by the develop- 
ment of the fungus, and aggravated by heat, the moisture of the 
sweat, and the friction of apposed surfaces of the skin in contact 
with each other and the clothing. After detecting the fungus in 
scales scraped from the surfaces thus involved, one is always in such 
case impressed with the characteristic clinical peculiarities of the 
disease. It is usually of symmetrical distribution, due to the circum- 
stances of its development, and in this respect differs from the other 
manifestations of the disease. 

When the nails are affected, the disorder is termed Tinea Tricho- 
phytixa Unguium, or Onychomycosis. These appendages of the 
skin then become friable, opaque, and lamellated ; and are clinically 
indistinguishable from nails secondarily changed in eczema, psoriasis, 
and similar disorders of the integument. One or several of the 
nails of both feet and hands may be affected. When all the nails 
of both extremities are involved, the disease is rarely of parasitic 
origin. The microscope is requisite for establishing the diagnosis in 
such cases, the parasite being detected in the fragments procured by 
scraping the nail. • 

Etiology. — The disease is caused by the presence of the parasite, 
though the latter may be an accident of other cutaneous disorders. 
The trichophyton was first discovered by Gruby, in 1844 ; though 
Malmsten, whose name is often associated with that of the fungus, 
became identified with its recognition, by his observations during the 
succeeding year. As a contagious disease, it ranks higher in the 
scale than favus, being much more readily communicated ; and, as a 
result, much more common. Occurring upon the non-hairy portions 
of the body, it is often spontaneously removed by the desquamative 
process which it excites in the skin. 

Though the fungus is the essential cause of the disease, its develop- 
ment is greatly favored or retarded by external influences. Attention 
has been already called to its luxuriance under the influence of heat 
and moisture. It is, hence, much more severe and rebellious to 
treatment in tropical countries. It occasionally occurs in epidemic 
forms. Thus, Gerlier 1 gives the details of such an epidemic in 
Ferney- Voltaire, where twenty-six cases came under his observation. 
In some of these the lesions were pustular ; in others, tuberculo- 
pustular. Aggravated forms of the disease seem also to originate in 
the lower animals. I have seen certain mild types of ringworm 
transmitted to man from cats and dogs. Gerlier concludes that the 
most rebellious and persistent forms are derived from the horse ; 
those from the cow being of less formidable character. Tilbury Fox 

i Lyon Medical, April 24, 1881, p. 590, and May 1, p. 7. 



TINEA TRICHOPHYTINA 



607 



reports au especially aggravated case originating in the disease as it 
existed upon a pony. It occurs much more frequently in children 
than in adults, presumably from the relatively tender condition of 
the epidermis in these subjects. It is particularly liable to occur in 
men whose skins are especially moistened, as in those who work in 
atmospheres saturated with steam. Several members of a single 
household will often display ringworm of the body at the same time, 
having transmitted it, the one to the other. Duhring and Fox are 
in accord respecting a belief in the need of an appropriate soil for 
the germination of the fungus, some individuals being thus predis- 
posed to its invasion. It is, however, encountered in both sexes and 
in all social conditions. 

Pathology. — The seat of the fungus in tinea circinata is between 
the strata of the epidermis, that part of it more particularly which 



Fig. 80. 




Epidermis invaded by trichophyton. a, iuferior portion of the stratum curiiemu ; 6, superior 
portion of the rete. Both exhibit long mycelial threads, with a few ramifications and a small number 
of spores. (After Kaposi.) 



lies immediately beneath the stratum corneum, the superior layers of 
the rete. Here the trichophyton can be discovered with the micro- 
scope ; at an early stage of the disease, in the form of spores only ; 
in the course of a few weeks, exhibiting characteristic mycelium. 
The latter is much more scantily developed than in favus ; much less 
branched and reticular; and the threads more slender. Like the 
elements in favus, however, these are jointed and divided into com- 
pound cells by partition walls. The spores are also often strung 
together like the beads on a necklace. The former measure 0.0018 
to 0.0026 mm. ; and thelatter, 0.0021 to 0.0935 mm. (Duhring.) 
After the fungus has found its way to the surface of the skin 



608 DISEASES OF THE SKIN. 

favorable to its development, it penetrates the layers of the epidermis 
in every direction from the central point of invasion, the circle thus 
produced being characteristic of many forms in both the higher and 
the lower vegetable life. The irritation excited by the presence of 
thi< foreign body produces all the subsequent symptoms of a mild 
grade of superficially seated inflammation ; erythema, exudation and 
fine vesiculation, papulation, and, in severe grades, the production of 
tubercles and pustules. The desquamative symptoms are exfolia- 
tive; and represent, in a sense, the natural effort at relief; this effort, 
as remarked above, being often successful when the spores and myce- 
lia are thrown off with the effete, horny plates of the epidermis. 
When the nails are affected, the same fungus can be discovered in 
detritus of the nail-tissue, which has been macerated in dilute liquor 
potassse. Often, as a result of the impairment of the structure of 
this organ, and owing largely to the stratification of its body, the 
lamella? will be found in part to have undergone a caseous degenera- 
tion. 

Diagnosis. — Ringworm of the body is to be distinguished clinic- 
ally from eczema, psoriasis, seborrhcea, lupus erythematosus, herpes 
iris, and syphilis. All the varieties of eczema are noted for their 
greater degree of itching and infiltration, their much less defined 
border, coarser scales, decided absence of a circular contour, and 
history of contagion. Psoriasis does occur in circular and annular 
patches, often with a clear centre and insignificant, subjective sensa- 
tions. But its scales are lustrous and the tissue beneath them readily 
bleeds, showing deeper implication of the skin. The disease is often 
symmetrical in disposition ; occurs by preference upon certain regions 
of the body where ringworm is relatively infrequent ; and its history 
is that of a chronic disorder. Seborrhcea of the skin exhibits greasy 
or tatty crusts, which are never characterized by the peculiarly branny 
condition of the scales seen in ringworm of the body. The distinct- 
ion between these disorders on the scalp will be given later. Lupus 
erythematosus is often symmetrical, always chronic, and characterized 
by the development of multiple, annular patches, enlarging centrifug- 
al ly from a clearing centre. Herpes iris can be distinguished, first, 
by its predilection for the extremities; second, by the variegations in 
color which it displays and which are never seen in ringworm of the 
hands. Syphilis is multiform in its lesions, usually preceded by a 
history of infection ; and its distinctly circular patches, enlarging at 
the periphery, all exhibit either atrophic, ulcerative, or distinctly 
crusted symptoms, which suffice for their recognition. 

Pityriasis maculata et circinata is not characterized by vesicles ; is 
often symmetrical in development; occurs in oval rather than dis- 
tinctly circular patches ; and exhibits a characteristic tawny-yellowish 
shade of color not seen in ringworm. In eczema marginatum, the 
elevated border of the diseased surface, its situation (groins, armpits, 
pubes, etc.), its curved outlines, and the occurrence of fresh rings 
within the older, point to the nature of the trouble. 

But the microscopical discovery of the parasite is the chief, and, 



TINEA TRICHOPHYTINA. 609 

indeed, essential, method of diagnosis in tinea circinata. By the aid 
of a good fourth- or fifth-inch objective, the spores and mycelia 
are readily recognized in the scales scraped from the surface and 
moistened with dilate liquor potassse. Duhring calls attention to 
the care which should be had in distinguishing the fungous elements 
from cotton or wool fibres, fat globules derived from previously 
applied unguents for the cure of the disease, sebum, pus, and the 
nuclei of the epithelia. All confusion of this sort can be avoided by 
a careful study of the anatomical peculiarities of the trichophyton, 
recalling especially the parallelism seen in the double contours of the 
threads, their jointed appearance, their contained granules, and the 
necklace-like or beaded arrangement of many spores. 

Treatment — The indication in the treatment of ringworm of the 
body, is the removal of the superficial layers of the epidermis, by 
which means the spores and mycelia are thrown off from the surface; 
and, if possible, the simultaneous destruction of the latter. Upon the 
delicate skins of infants and children, the simpler remedies are first 
to be employed. Scrubbing each patch with the spirit of green soap, 
or merely soap and water, will often suffice for its obliteration. The 
topical application of tincture of iodine is a common and usually 
effective remedy. The same may be said of dilute acetic, boric, and 
carbolic acids. Morris's solution of thymol, 1 half a drachm to two 
drachms (2.-8.) of chloroform, and six drachms (24.) of olive oil, is 
equally available. One may also use thymol in ointments, half a. 
drachm (2.) to the ounce (32.) of simple unguent, with good effect. 
Of the mercurials, ammoniated mercury, a scruple (1.33) to the 
ounce (32.) of ointment; corrosive sublimate, one to two grains 
(0.066-0.133) to the ounce (32.) of solution ; and the ointment of the 
nitrate, one drachm (4.) to the ounce (32.) of vaseline, are preferable. • 
Sulphurous acid from a freshly opened can, and saturated solutions 
of the hyposulphite of sodium are as effective as any of the parasiti- 
cides, and are often used with advantage as lotions to be followed by 
an appropriate unguent, always providing against chemical decompo- 
sition of the ingredients of the latter. Sulphur- and tar-containing 
lotions and unguents are useful in more obstinate cases. 

Chrysarobin and pyrogallol, in ointment from five to ten grains 
(0.33-0.66) to the ounce (32.), are brilliantly effective in all these 
cases, subject, however, to the disadvantage incidental to the staining 
and irritative effects they produce. They should be used with cau- 
tion upon the skins of children, and always tentatively at the onset. 
In cases of ringworm on the face of male adults, close to the beard 
or scalp, one may employ these remedies with a view to insure the 
non-invasion of the pilary follicles by the fungus, whose prompt de- 
struction may become then a matter of urgency. Wilkinson's oint- 
ment, recommended by Kaposi, is also useful in the treatment of 
aggravated forms of ringworm of the body, but should be restricted 
to such cases. For other and more urgent reasons, caustic potash 

1 Lancet, 1881, pp. 164 and 241. 
39 



610 



DISEASES OF THE SKIN. 



solutions should be reserved for exceedingly intractable eases. Some- 
times a combination of several of the simpler remedies named above 
may be serviceable, as in the following formula: 



R. Lac. sulphur. 
Sapon. virid. Bpts. 
Lavandul. tr. 
cerin. 



Sijss; 




10 




a 3vj ; 




24 


38a ; 




■i M. 

[Kaposi. 


5'.i ; 
oj; 




64j 

32| 


"I xx ; 

toiij; 

toii.i: 

3j; 

3.1 : 
of adults. 


[V 


1 
12 
12 

4 

32 

anH 


33 

M. 
irlingen ] 



lodin. pur. 

01. picis [sp. gr. 0.853] 
Mix with care, gradually. 

R. Creasoti. 

01. cadini 

Sulphuris prpecip. 

Potass, bicarb. 

Adipis 
To be used in obstinate ringworm of adults 

Dr. R. "W. Taylor applies the bichloride of mercury, four grains 
to the ounce, in tincture of myrrh. Dr. Perry, of California, uses 
the metal in one-half of the strength last named, dissolved in sul- 
phuric ether. Foulis, of Edinburgh, recommends iodine dissolved in 
the oil of turpentine or benzine, the fluids named penetrating with 
greater ease than others, to the deeper portions of the skin. 

Other articles advised by authors are the oleates of mercury and 
copper (?), croton oil, glacial acetic acid, cantharidal collodion, petro- 
leum, and pyroligneous acid (Thomas). 

The thorough application of the remedy selected for use, upon the 
integument quite freed from its scales by scrubbing with soap and 
water, is a matter of some importance. When the solution of sodic 
hyposulphite is employed, the previous application of dilute vinegar 
and water by sponging, renders the agent more effective, for evident 
chemical reasons. Overtreated skins, or those to which too strong 
a parasiticide has been applied, require subsequent relief of the 
induced irritation by the simpler bland dressings. The inert dusting 
powders, even when not thus indicated, are often useful when there 
is distinct vesiculation ; and in simple cases may be the sole remedies 
required, as then the disease is self-limited in duration. 

Liborius, having observed in China that the tincture of an unknown 
fibrous root was used successfully as a remedy for ringworm, obtained 
some of the plant, which was found to be the Ithinacanthus communis, 
whose leaves, bruised and mixed with lime juice, are used in India 
as an application for the same complaint. Liborius has since ob- 
tained from the root a quinine-like body, supposed to be the active 
constituent. It resembles chrysarobin in being antiseptic and anti- 
parasitic. He proposes to call it rhinacauthin, and represents it by 
the formula C 14 4 18 4 . 

The internal treatment of patients affected with ringworm, by 
means of tonics and roborant measures, may be demanded bv the 



TINEA TRICHOPHYTINA. 611 

systemic condition, but has no recognized influence over the disease 
itself. 

When the nail is involved it should be thoroughly scraped, and 
then kept moist by wearing over it the rubber cots sold in the shops 
for the use of sportsmen, fishermen, and others. In this way a par- 
tial maceration of the nail substance is secured, and the action of any 
one of the parasiticides named above, greatly aided. 

Prognosis. — The disease is often self-limited, and is generally, 
under the simplest treatment, satisfactorily relieved. Eczema mar- 
ginatum, especially in the crural region, may be obstinate ; and this 
because it is an eczema as well as a parasitic disease, and therefore 
subject to the relapses and chronic phases of the first-named disorder. 
Other intractable forms of the malady do, however, occasionally occur 
in adults, usually in tropical climates and tropical temperatures. 

Tinea Imbricata. Tokelau Ringworm. Burmese Ring- 
worm. Malabar Itch. — Under these names and others of similar 
character, have been described exaggerated forms of a contagious 
cutaneous disease produced by a vegetable parasite whose identity 
with the trichophyton, though not established, is probable. Tinea 
imbricata, as described by Manson; the Tokelau Ringworm, described 
by Turner, and the affection reported by MacGregor as occurring in 
the Soloman Islands and the New Hebrides, may be identical. The 
parasite does not extend deeply within the corium, but is found in 
luxuriant vegetation with preponderance of rather irregularly con- 
toured spores. The clinical symptoms are, exaggerated desquamation 
of ichthyotic flakes in large concentric circles even a quarter of an 
inch apart ; the formation of these concentric rings by recrudescence 
of the disease within its annular limits; the production of large fes- 
toons of lesions even upon the exposed surface of the face; and 
evidence, at times, of excessive irritation of the skin excited by the 
fungus, in the form of pustular and even furuncular and tubercular 
lesions. 

According to Manson, the fungus of tinea imbricata, differs from 
that of ordinary ringworm in that the former is more abundant ; its 
threads longer, and its spores more irregularly outlined. 

[B.] Tinea Tonsurans. 

Tinea Tonsurans is a cutaneous disease of the scalp, characterized by the 
occurrence of one or several, circumscribed, non-elevated or tumid patches, 
over which the hairs are usually fractured at a point near the integument, 
producing thus the effect of partial baldness, while the scalp itself is the 
seat of vesiculation, scaling, or crusting, the disease being produced by the 
presence of the trichophyton. 

Symptoms. — The differences to be particularly noted between ring- 
worm of the body and ringworm of the scalp, depend largely upon 
the fact that in the latter, the fungus makes its way to the hair- 



612 DISEASES OF THE SKIN. 

follicles, and there finds the nutriment for its multiplication and 
de\ elopment. 

It is usually first observed in the form of circumscribed, small 
coin-sized, roundish patches upon the scalp, wholly or partly covered 
by minute, whitish, slate-colored, grayish, or dirty yellowish scales. 
Rarely, the formation of the latter can be noted as consequent upon 
an hyperaemic and reddened condition. Still more rarely, pin-point 
sized, transitory vesicles or pustules precede. The hairs upon such a 
patch seem irregularly clipped short near the surface or, as it is fre- 
quently styled, "nibbled" off, thus producing the effect of partial 
baldness in the involved area. Among them may be often found 
lustreless, dry, long - , and fragile hairs, which break upon slight trac- 
tion or flexion. The patches may increase in number and spread 
individually in area till, in the course of weeks or months, the entire 
seal}) is invaded. In the older patches, young and downy hairs may 
be seen here and there, pushing up among the stumps left by those 
that have fallen. One or more of various phases of the disease may 
be presented in its subsequent evolution. Thus a single patch may 
extend to the size of a large coin or the palm, and the disease be 
throughout limited to that area. Again, as just related, almost the 
entire scalp may be covered by relatively small or enlarging patches, 
or, even without the occurrence of any distinct patch, isolated hairs 
or tufts of hairs here and there over the entire scalp may exhibit 
evidence of impairment. The disease may be acute or chronic in its 
course. Instead of assuming the dry and squamous type described, 
acute and exudative symptoms may develop, in which event the rare 
vesicular and pustular lesions are succeeded by the exudation of a 
gummy secretion and the formation of crusts. Lastly, the variety 
known as kerion may be produced, which is described below. 

Pruritus, in various grades of severity, though usually mild, is 
induced by the disease; and often the patches are altered in appear- 
ance by the traumatisms produced by the finger-nails and the comb. 
When the scalp is very generally invaded by the squamous form of 
the disorder, its appearance is very similar to that noted in diffuse 
seborrhea, chronic eczema, and psoriasis of the scalp, except that the 
hairs are less pasted to the surface; are more lustreless, friable, and 
contorted in shape; and much more often represented by stubble or 
stumps. The disease may occur coincidently with ringworm of the 
body, and indeed at times a ring may be detected, half of which 
on the neck presents the typical aspect of tinea circinata, and the 
other half involving the seal]) exhibits the features here described. 
Stowers, 1 Sangster, 2 as also Hutchinson, Tav, Hillier, Baker, and 
others have recorded cases in which the disease coexisted with alo- 
pecia areata. The author has certainly observed this occurrence but 
in one case, where the evidence was conclusive that there was mere 
coincidence and no causal relation between the disorders named. 

Geber asserts that after exfoliation of patches of ringworm, the 

1 Lancet, 1881, p. 326. 2 Id., 1880. p 303. 



TINEA TKICHOPHYTINA. 613 

scalp may become absolutely bald, smooth, and glossy, but that hair- 
stumps and scales in the environment indicate the nature of the 
disease, which is thus often mistaken for area Celsi, or alopecia 
areata. 

Lastly, it is to be noted that here also at times the efforts of nature 
are successful in procuring spontaneous relief. With the defluvium 
capillitii and exfoliating epidermal plates, the fungus may be finally 
removed ; the resulting alopecia be followed by a growth of healthy 
pilary filaments ; and, even though years be required for this long 
process, in the end no trace of the disease be discernible. 

Etiology. — Ringworm of the scalp is produced by the same fungus 
as that recognized in the etiology of tinea circinata, the trichophyton. 
It is frequently observed in children of both sexes, especially in those 
gathered together in schools and public charities, where it may spread 
very generally from one to another, and require months and years 
for its extermination. It is a highly contagious disease, but yet re- 
quires unquestionably a suitable soil for its development. I have 
been frequently impressed with a fact in this connection to which 
Dr. White 1 calls attention. When there is ringworm on the face of 
au adult, even of rebellious form, in the course of which the beard 
may be extensively affected, the scalp is usually spared. Ringworm 
of the scalp in the adult and aged is, indeed, among the rarest of 
cutaneous accidents. Among the methods of transmission in chil- 
dren are, the use upon the heads of the unaffected, of brushes, combs, 
wearing apparel, sponges, towels, etc., which have been employed 
upon persons exhibiting ringworm of the body or head. It must 
be remembered that tinea circinata may transmit tinea tonsurans ; 
and it is by traciug the course of the two forms of the disease, that 
the sources of contagion can be ascertained in any series of cases. 
The disease is one rather prevailing in the cities than in the country ; 
and in this respect also differs from favus. 

Pathology. — The disease is produced in consequence of the inva- 
sion of the scalp, and follicles, bulbs, and shafts of the hair, by the 
trichophyton, the fungus already described as the cause of tinea 
circinata. This vegetable mould is much more abundantly developed 
about the hairs than the achorion Schonleinii, and its presence is, 
hence, much more readily demonstrated in these structures. 

Robinson 2 has lately excised a portion of a scalp affected with 
tinea tonsurans ; and found the stratum corneum, especially in its 
upper layers, largely invaded by spores, as also the rete, the external 
root-sheath of the hairs in its upper portion, the corium, and sub- 
cutaneous tissues. Myceliawere abundant iu the mucous layer. He 
concludes that the anatomical seat of the disease differs in different 
cases. 

Under the microscope the hairs themselves, in advanced cases, are 
seen to be greatly altered. The bulbs are distorted, misshapen, or 
withered, and often stuffed with spores which greatly predominate 

1 Ijoc. cit. 2 jf ew York Medical Journal, 1881, vol. xxxiii. p. 289. 



014 



DISEASES OF THE SKIN 



over the mycelia. At times the base of the bulb will show a brush- 
like expansion, and in this respect resemble the free ends of the 
stumps of the hairs above, which have a jagged, bristle-like appear- 
ance, from the division of the shaft into many filaments between 



Fig. 81. 




v 



lair invaded by the trichophyton. 



^-$P' 



which spores in abundance are visible. The shaft is often longitu- 
dinally split, where the parasitic growth has mechanically forced 
apart its elements, and its cuticle may be peeled off, or curled above 
and below away from the axis, with spores protruding at such points. 
Conidia can be discovered much further upward along the hair and 
distant from the scalp than in favus ; often, indeed, upon its free 
surface. Occasionally a few mycelial threads may be recognized, 
either longitudinally or transversely arranged as regards the axis. 
It is probable, however, that the relative preponderance of spores 
and mycelia in these filaments is determined by the stadium of the 
disease in any given case. In the earlier stages of the affection the 
elongated threads may be discovered in larger quantity ; and as they 
interfere less with the integrity of the fibrous tissue, the hair may 
usually at these times be extracted from its follicle without fracture. 
Later, the threads disappear and the conidia are infiltrated throughout 
every portion of the shaft which then breaks, often upon the slightest 
traction. One unaccustomed to microscopical examinations, with a 
view to the detection of the parasite, should be careful not to mistake 
for these threads the delicate lines traversing the surface of the shaft 
exposed to the objective, and which represent the edges of the cuticle 
of the hair. The fungus, though ordinarily refractory to the action 
of coloring matters, will be stained by eosine and methyl-violet. 
The scales found upon the affected seal)) also exhibit traces of the 
trichophyton under the microscope, though to a less extent than the 
invaded hairs. In exceptional cases, however, the epidermis of the 
seal]) seems to suffer as much as that of the non-hairy portions of 
the body. 



TINEA TRICHOPHYTINA. 615 

Diagnosis. — The recognition of a typical patch of ringworm of the 
head is simple. The branny scales, stumps of hairs, and distinct 
contour of the invaded area, are always in the highest degree suspi- 
cious symptoms. It has been stated, however, that the general 
development of tinea tonsurans over the scalp produces a condition 
very like that seen in other diseases. In such cases the microscope 
must be employed for a decision as to the nature of the process. I 
have seen the whole vertex unnecessarily epilated in seborrhoea sicca, 
when no parasite could be found. But in seborrhoea there is usually 
a symmetry of involvement which even aggravated cases of ring- 
worm of the head fail to assume ; and even though pasted down, 
atrophied, changed in color, and loosened in their follicles, the hairs 
are rarely broken off near the scalp in seborrhoea. In seborrhoea, 
psoriasis, and squamous eczema of the scalp, there is, moreover, no 
history of contagion ; the scales are in each disease different in color 
and character ; and the hairs in the two last-named affections are 
firmly seated in their follicles, and only in severe cases present nutri- 
tional changes. The diseases, moreover, are usually chronic in their 
course. In any doubtful case, apart from microscopical evidence, 
thorough removal of all scales from the scalp by shampooing with 
green soap and hot water, will reveal the nature of the disease 
present. 

Alopecia areata, as has been noted above, may coexist with ring- 
worm, but it is pathologically distinct from it. The patches in the 
first-named disease are uniformly smooth, and the hair falls from them 
en masse, without lesions, stumps, or other traces of its former devel- 
opment in the regions affected. I have, however, often seen blackish 
points or dots distributed over the areas which characterize this form 
of alopecia, and which certainly constitute suspicious symptoms in 
any case. In such event, one may be able to pick out with a fine 
needle this blackish point from the patent follicular orifice, and 
find it to be a particle of dust accidentally lodged in the depres- 
sion. It is not, as in comedo, free pigment which has found its way 
to the surface ; nor, as in ringworm, the stump of a hair on a level 
with the superficies of the scalp. In favus, the cup-shaped crust 
will sooner or later betray the character of the disease to the naked 
eye. 

Confirmatory evidence as to the nature of the disease will ofteu be 
furnished by a careful search for the source from which it was de- 
rived ; and for obvious reasons this should be always attempted. 

Ringworm of the body occurring upon the individual patient 
affected with tinea tonsurans, or other members of the same house- 
hold, and suspicious "mangy" patches upon horses, dogs, cats, 
rabbits, -white mice, or other animals with which the child may have 
been in contact, should always receive attention. 

Treatment — The indication for the relief of the disease is the 
destruction of the parasite ; and there can be no question but that 
this may be accomplished in some cases without having recourse to 
epilation. The parasiticides named in connection with ringworm of 



616 DISEASES OF THE SKIN. 

the body, if* thoroughly applied in simple eases, after clipping or 
shaviDg the hair and an efficient scrubbing of the patch with spirit 
of green soap and water, will occasionally be followed by permanent 

relief. Prominent an g these parasiticides may be named : pyro- 

ligneous acid, sulphurous and boric acids, saturated solutions of the 
sodie hyposulphite, acetum cantharidis, tincture of iodine. Morris's 
solution of thymol in chloroform and olive oil (see tinea circinata), 
ointments of boric acid and sulphur, of each a drachm (4.) to the 
ounce (32.) of vaseline, and chrysarobin, the action of the latter 
being carefully limited to the patch of disease by the aid of a skull- 
cap 

Epilation is, however, a valuable, and occasionally essential, method 
of treating the disease ; and may be practised, as already recom- 
mended, in considering the treatment of favus. The scalp in each 
case should be first oiled, and cleansed by the soap shampoo, and, 
alter the epilation is performed, an appropriate parasiticide should be 
employed. The calotte, made by spreading pitch plaster upou leather 
or muslin, is a brutal substitute for epilation in order to remove the 
hairs, but the sticks recommended by Bulkley may be employed, the 
formula for the preparation of which has been already given. In 
each case, the epilation should remove a zone of sound hairs encir- 
cling the diseased patch, that the encroachments of the fungus may 
be in every possible way limited. It should not be forgotten, how- 
ever, in the treatment of tinea tonsurans by both epilation aud para- 
siticides, that in chronic cases these methods, in the hands of the most 
expert, have failed for consecutive months to relieve radically the 
disease ; that even the most inveterate cases, in the course of time and 
as adult years are reached, are spontaneously relieved without perma- 
nent alopecia ; aud that no remedy or procedure is ever justifiable 
which is capable either of producing follicular atrophy, or an effect 
worse than that wrought by the disease itself. 

Coster's paste is popular among English practitioners, including 
Stow r ers, Fox, Liveing, and others. It contains two drachms (8.) of 
iodine in crystals, slowly dissolved in the oil of tar; and is painted 
over the part at intervals of a few days. It is most useful in circum- 
scribed patches of the disease. Among other remedies employed, 
some of which have been described in connection with ringworm of 
the body, may be named, the corrosive chloride, ammouio-chloride, 
red oxide, oleate, and ointment of the nitrate of mercury; pure 
carbolic acid and carbolated glycerine ; and sulphur, chloroform, 
ether, and tar in ointment. 

In order to be effectual, the treatment pursued must be persistent, 
thorough, and always accompanied by frecpnent washings and soap- 
ings of the affected part. 

The induction of suppuration in the hair-follicles (or a species of 
artificial kerion) by the aid of croton oil liniment, has been praised 
by Alder Smith and Wyndham Cottle, of London, and lately, in a 
modified form, by Magee Finny, of Dublin. By the latter process, 
one hundred parts of the oil are mixed with fifty each of cacao 



TINEA TRICHOPHYTINA. 617 

butter and white wax. Sticks are made of the compound which 
can be thoroughly rubbed into the part affected. By both methods, 
it is claimed that no pain is produced, nor is permanent alopecia the 
result. A solution of salicylic acid is applied after each treatment, 
and a subsequent poultice may be also needed. In these cases the 
parasite is presumably destroyed by the suppuration excited. 

Dr. James Foulis, of Edinburgh, claims to relieve the worst cases 
in a week by the following method : The patient (usually a child) is 
seated before a basin of warm water with a towel fastened around the 
brow so as perfectly to protect the eyes from the trickling into them 
of the fluids used. About the patches, the hair is cut short ; if the 
patches are numerous, the entire scalp is closely cropped. The oil 
of turpentine is first thoroughly rubbed in with the finger, causing 
the dirt and greasy scales to disappear while the short broken hairs 
are seen to stand up like bristles. The scalp is then well sham- 
pooed with hot water and ten per cent, carbolic soap. The head is 
then well dried and two or three coats of iodine in tincture are 
painted over each affected patch and permitted to dry. Carbolic 
oil, one part to twenty, is then rubbed into all the hairs of the head 
with a view to reaching any spores among them. The treatment is 
applied once or twice daily according to the severity of the case for 
a week. 

As in the case of ringworm of the body, tinea tonsurans is not 
remediable by internal treatment. Such internal medication, how- 
ever, may be indicated by the systemic condition of the little patients, 
and should be in each instance such as that condition suggests. 

Prognosis. — The ultimate prognosis in every judiciously treated 
case of tinea tonsurans is favorable, since all patients ultimately re- 
cover from the disease per se. Under the best treatment many cases 
will prove tedious, month after month passing without marked im- 
provement. The disease, however, in a large proportion of cases 
among children surrounded by proper hygienic conditions, especially 
as regards cleanliness, is readily relieved. 

Tinea Kerion. — The occurrence of active inflammation in a 
usually circumscribed portion of the scalp affected with ringworm, 
is at times followed by certain peculiar features, the assemblage of 
which has been designated by this term. This complication of the 
disease was recognized early in the history of medicine, by Celsus, 
whose name has since been associated with its lesions (Kerion Celsi, 
from KVP iov, a honey-comb). Tilbury Fox, in J 866, was first to recog- 
nize its identity with tinea tonsurans ; and it has since been the sub- 
ject of a number of interesting papers by Tanturri, Maiocchi, Schil- 
ling, Bardazzi, Auspitz, and Wilson. In this country, Dr. I. E. 
Atkinson, 1 of Baltimore, has made it the subject of a valuable 
memoir. 

The symptoms are, the occurrence of acute inflammation, usually 

1 Arch, of Derm., vol. vii. No. 1, Jan. 1881. 



618 DISEASES OF THE SKIN. 

circumscribed, though occasionally diffuse, in a portion of the scalp 
where a tumor forms which may project to a considerable distance 
above the genera] level. In time the appearance presented is quite 
suggestive of anthrax, as from tumid orifices of numerous distended 
follicles, a viscid, semi-transparent, and puriform fluid exudes. The 
latter is highly characteristic The hairs loosen and fall. When the 
view of the tumor is not obscured by the pilary growth, it appears as 
a flattened lien's to turkey's egg-sized, boggy, semi-globular tumor, 
its surface congested, reddened, glazed, and often exhibiting other 
evidences of inflammation, with split-pea sized, pustule-like lesions 
distribute*] over its surface, or, when these have ruptured, the gaping 
apertures described above, from which the gummy secretion is poured 
in varying quantities. Modifications of this condition occur, such as 
the production of a true subcutaneous abscess with fistulous sinuses. 
The sensations awakened are usually painful ; the course of the dis- 
ease is chronic. It may begin with the usual symptoms of ringworm 
of the head, though often there is no history of the latter. The com- 
plication is a rare one. But five cases in all have come under the 
author's observation ; two of these were children in one family, 
brought to him from a neighboring State. 

The parasite may and may not be found in patches of kerion, 
according to the acuity of the present or precedent inflammatory pro- 
cess. If the latter be of high grade and suppuration result, the 
fungus is destroyed, a result whose attainment has been attempted in 
the production of an " artificial kerion " by means of croton oil for 
the relief of tinea tonsurans. In the earlier stages, well described 
by Atkinson, and represented by merely deep-seated follicular in- 
flammation, with pustular development about the hair-shafts, the 
latter may be seen microscopically to be invaded with spores. 

The treatment is either by the milder parasiticides or by the 
methods proper for the relief of ordinary phlegmonous inflammation 
of the scalp, according to the stage of the kerion. 

[0.] Tinea Sycosis. 

Tinea Sycosis is a contagious disease of the region covered by the beard of 
the adult male, in which the integument, hairs, hair-follicles, and subcu- 
taneous tissues may be involved, characterized by the occurrence of macu- 
lar, papular, vesicular, pustular, or tubercular lesions, owing to the pres- 
ence of the trichophyton. 

Symptoms. — The disease is best studied at its onset, in the beard 
of a blonde subject with relatively fine downy hairs, where are pre- 
sented the typical features of tinea circinata, ringworm of the body. 
One or several, reddish, pea- to small coin-sized rings become visible, 
with pin-point sized vesicles, branny scales, and often, indeed, no 
other lesion save an hyperaemic, scarcely elevated margin at the 
periphery. The hairs over the patch may be fragile, and clusters 



TINEA TRICHOPHYTINA. 619 

here and there betray evidences of change. With proper treatment 
the disorder may not progress beyond this point. 

In other cases the very slight degree of itching awakened by the 
process just described, may be intensified, and large plaques form, a 
portion of which may extend from the region of the beard over the 
face and neck, or vice versa. When fully developed, a phlegmonous 
disorder is produced which bears some analogy to the kerion just de- 
scribed, and which may so actively progress that it is first seen in 
typical development. The skin is congested and reddened, with sub- 
epidermic (or debris of ruptured) pustules at the orifices of the pilary 
follicles ; and is studded irregularly with firm, pea- to nut-sized 
papules and tubercles. The latter are usually aggregated in masses 
or lumps which involve the skin and subcutaneous tissues ; and are 
firm, often tender and painful, rarely boggy and furuncular. When 
pierced, they give exit to a characteristic, muciform, gluey, yellowish, 
and sticky fluid, puriform yet differing from pure pus, which rapidly 
dries into crusts. These composite lesions are usually circumscribed 
in a given area of involvement, very rarely covering the region of 
the beard in symmetrical disposition, more often limited to one cheek, 
or the cheek and chin. Duhring has an admirable portrait of this 
disease in his Atlas, one of the most faithful representations of a 
cutaneous affection which it is possible to produce. 

The hairs in the invaded region are involved as in ringworm of 
the scalp. These filaments break near the surface of the integument, 
leaving ragged stumps ; or spontaneously fall, after being loosened 
in their follicles. 

The ease with which they may be epilated is really one of the most 
characteristic features of the disease ; they are slipped out of their 
follicles as readily as if they had been oiled ; or, as Anderson re- 
marks, "as easily as a pin can be pulled out of a pin-cushion." 
They are then often whitish because enveloped in the fungus pro- 
ducing;: the disease. In either event, the resulting, gradual thinning;, 
or removal of the hairs, renders the disease of the surface more con- 
spicuous and deforming. At the edges of a patch thus exposed, de- 
formed, lustreless, contorted, flattened, twisted, or split hairs may be 
found. Occasionally the features of the patch are changed in conse- 
quence of the unusual degree of suppuration excited. In such case 
the pustules burst, and their contents concrete into dry crusts about 
the stumps of shafts of surviving hairs, from which circumstance the 
disease has received its name (sycosis, avuov, a fig). Rarely, a con- 
glomerate crust covers the entire region with an excoriated, inflamed, 
and secreting surface beneath. 

During the last few years the author has had the opportunity of 
treating a number of formidable cases of tinea sycosis in the persons 
of farmers, resident in the extreme western States, where the disease 
was long untreated and unrecognized. A few of these severe cases 
were produced after shearing sheep having diseased pelts. In these 
cases the cheeks, lips, and chin were the seat of large-nut to small- 
egg sized, cutaneous and subcutaneous, soft, boggy, and pus-filled 



620 DISEASES OF THE SKIN. 

tumors, accompanied by excessive soreness of the entire throat and 
neck, the hair falling- from the follicles in large masses, and as if 
lubricated to facilitate their escape. 

Etiology. — The disease is always produced by the trichophyton, 
the fungus described as the cause of ringworm of the body and scalp. 
It was first discovered by Gruby, in 1844. Dr. White, 1 of Boston, 
has called special attention to the frequency of its origin in the 
barber's shop, a fact which common experience verifies. It is usually 
the irregular visitor to these establishments who is first to supply the 
germs of the disease. No individual proprietorship in mug, soap, 
brushes, and razor can secure, against danger of infection, the person 
whose razor is drawn over a common strop, whose cheek is handled 
by unwashed fingers which have been recently passed over an infected 
face, or whose beard is combed, brushed, or rubbed by the imple- 
ments and towels in common use at these establishments. The 
remedy is twofold; first, the full beard should be worn without 
shaving, as it is very rare to find bearded patients of this class affected 
with tinea sycosis • second, where the whole or any part of it is to be 
removed, every adult male should learn how to shave himself. The 
physician should, in this connection, be for medico-legal reasons put 
upon his guard against hastily deciding both as to the nature of the 
disease of his patient and the source from which it was derived. Of 
the first, he can become certain by his microscopical investigations. 
Of the second, he can only become certain by obtaining possession of 
facts far beyond the reach of the average practitioner. A medical 
gentleman in a neighboring State recently sent the author for exam- 
ination some hairs from the beard of a male patient affected with 
tinea sycosis. Before receiving a report confirming the diagnosis, 
this physician was sued by the barber in whose establishment the 
disease had been probably acquired, on the ground of libel. 

It is difficult to determine the frequency of the disease from 
statistics. The affection is certainly relatively rare, and yet more 
common than is frequently supposed to be the case. In the author's 
practice it is of irregular occurrence, months passing without a single 
case coming under observation, after which several may be noted in 
rapid succession. The statistical returns of the American Dermato- 
logical Association include eighty cases in the year 1885; ninety- 
seven in the year 1886 ; and but twenty-two in the year 1887. 

The disease, being contagious, is one affecting men in all stations 
of life, and these usually at a period rather under than over the 
fortieth year. The author has certainly treated for this disease more 
men with light hair and eyes, and light brown, reddish, or sandy 
beard, than those having darker shades of hair and eyes, a fact to 
which Mr. Morris has called attention in connection with tinea 
tonsurans. 2 

Pathology. — The disease is essentially a follicular and perifollicular 
inflammation, induced by the irritative effects of the fungus, pre- 

l Loc. cit. "- Lancet, 1881, pp. 1C4 and 241. 



TINEA TKICHOPHYTINA. 621 

cisely as in the case of tinea tonsurans. The reason for the difference 
between the clinical aspects of the two diseases, may be in part 
explained by the habitual covering of the scalp with caps and hats, 
while the face is left exposed; and by the occurrence of tinea sycosis 
in adult years, while tinea tonsurans is emphatically a disease of 
childhood. As a result of the induced inflammation, the vesicles, 
pustules, papules, and tubercles are formed, w T hile the perifollicular 
inflammation may invade all portions of the skin and subcutaneous 
tissues, gluing together the plastic nodules formed about the individual 
hair-sacs, into the lumpy masses which are so characteristic of the 
disease. The invasion of the hair-follicles and hairs by the fungus, 
is accomplished as in the case of ringworm of the scalp. Under the 
microscope, spores and mycelia are visible, the former preponderating 
at the stage where the disease first comes under observation, but 
probably preceded in most cases by abundance of thread-like forms. 

Fig. 82. 




Filaments and spores of the trichophyton from the heard of a patient affected with tinea sycosis. 

The identity of the disease with ringworm of the body and scalp, 
does not, however, rest merely upon microscopical observation, but is 
demonstrable by established clinical facts. Not only may ringworm 
be seen to spread from the face to the beard, but tinea tonsurans and 
tinea circinata may transmit tinea sycosis, and the reverse. I lately 
treated a physician for ringworm of the bearded chin and cheek 
derived from the face of a little patient under his care. He subse- 
quently gave tinea circinata to his wife, who suffered on the face and 
shoulder, and she, in turn, communicated tinea tonsurans to her 
daughter. 

Diagnosis. — The distinction between the parasitic and non-parasitic 
forms of sycosis, is of chief importance in this connection ; and, 



622 DISEASES OF THE SKIN 

necessarily, the microscope must be employed to settle the question 
definitely. The diseases, however, differ in their clinical features 
The non-parasitic form always fails to exhibit the nodules, tubercles, 
and composite cutaneous and subcutaneous agglutinations of the dis- 
ease produced by the fungus. The disease in the former is a more 
superficial process, and, in the author's experience, exhibits to the eye 
a more vivid redness as a result of the cutaneous hyperemia. Owing 
to the same cause, the frequent pus-containing lesions are developed 
and elevated above the general level of the integument; they are 
less commonly sub-epidermic crypts filled with characteristic mucoid 
puriform contents. The region of the bearded upper lip, so often 
involved in eases of chronic nasal catarrh with coryza, is apt to be 
spared by the trichophyton. When the latter is present, the hairs 
are characteristically loosened, distorted, and otherwise changed. 
This is not seen in the non-parasitic form of the disease. Exception, 
however, in this particular is to be noted in some long-standing cases 
of non-parasitic sycosis. When the latter affection has persisted for 
many years (and one may often see such patients), the thinned and 
starved condition of the pilary growth is a striking symptom, the 
scanty lustreless hairs often scarcely sufficing to conceal the deforming 
redness and pustulation of the surface from which they spring. In 
another point, the author's personal experience seems to differ from 
that of some other observers. The diffuse symmetrical affection of 
the hairy face, extending over both cheeks and chin, has been by him 
more frequently recognized as unconnected with the presence of a 
parasite. Lastly, the parasitic is, as a rule, less painful and tender 
than the other form of sycosis; and is, without question, furthermore 
of much rarer occurrence. 

As distinguished from syphilis, it is to be remarked that the 
papular or pustular syphiloderm developed in the beard is, almost 
without exception, to be discovered in other parts of the body, espe- 
cially the scalp. Ringworm of the scalp and beard, existing at the 
same time in one individual, the author has never seen. In syphilis, 
there is usually au offensive odor to the abundant crusts ; shallow 
ulcers are also apt to form beneath the pustules ; and there is often a 
history of infection or a hint of the nature of the disease in its poly- 
morphic character. 

Eczema of the bearded region may extend to or from other portions 
of the face, as in the case where it sweeps down from the ear above. 
The presence of a stalactitic crust, depending from the lobe of the 
ear of an affected side, would at ouce furnish a clew to the nature of 
the disease in the beard. In eczema, the interfollicular region is 
invaded ; not deeply, as in tinea, but superficially, as in non-parasitic 
sycosis. The itching is severe; the hairs not involved; the infiltra- 
tion diffuse ; the outline indeterminate ; and a halo of redness spreads 
from the affected part to the non-hairy surface in the vicinity. 

Treatment. — The treatment of tinea sycosis is generally conducted 
as in tinea tonsurans. It is customary to begin by anointing the 
affected surface with an oily or fatty substance, and to follow this 



TINEA TEICHOPHYTINA. 623 

with a shampoo of soap and warm water for the removal of crusts, 
after which shaving and epilation are practised on alternate days ; 
and parasiticides employed locally. For the softening of the crusts, 
the spray of the atomizer may be used. 

Epilation of the male beard is often essential for the removal of 
the disease, but the author believes that the results of the treatment 
suggested below, are in the end often as satisfactory. It is true, that 
a month or more may be required for the removal of the disease, but 
that is often the period of time during which treatment by epilation 
must be pursued. 

The patient for two successive days keeps the affected part macer- 
ated with almond or olive oil. On the evening of the third day, 
the shampoo with soap is employed, and the skin washed free from 
all crusts and scales. The part is then cleanly shaved. The first 
is more painful than any subsequent similar operation. After the 
shaving, the affected surface is bathed for ten minutes in water as hot 
as can be tolerated, by which means the inflammatory condition of 
the perifollicular tissues is, in a brief time, considerably reduced. 
While the bathing is in progress, all sub-epidermic pustules or points 
where a mucoid fluid is coming to the surface, are opened with a fine 
needle. A solution of the hyposulphite of sodium is then sponged 
freely over the surface for several minutes. This may contain a 
drachm (4.) to the ounce (32.) or even more. After a thorough and 
final washing with the hot water, the tender skin is carefully dried 
and gently smeared with a sulphur ointment, containing one or two 
drachms (4.-8.) to the ounce (32.) of vaseline. The patient then 
retires to bed. In the morning, the unguent is washed off with soap 
and water, the sodium solution reapplied, and a salicylated powder 
thoroughly dusted, and kept over the part during the day. In the 
evening, the shaving may be repeated or not, according to the vigor 
with which the beard is reproduced, but on the second day this is 
imperative. As soon as the pustulation ceases and the tubercles have 
manifestly diminished in size, the ointment at night is superseded by 
the use, at that time also, of the dusting powder. Whether the 
shaving is practised nightly or on alternate nights, the ablution with 
very hot water and with the solution of the hyposulphite of sodium, 
is continued nightly until the inflammation excited by the fungus is 
practically limited to the follicles which are invaded. The dusting 
powder is to be thoroughly and constantly employed after the oint- 
ment is discontinued. With care and patience, the author has suc- 
ceeded by these measures in saving a number of patients from the 
annoyance of epilation. The treatment should be continued for 
several weeks after the apparent relief of the disease. 

The treatment may be varied to suit the needs of individual cases, 
Kaposi highly recommends, for example, one per cent, solutions of 
corrosive sublimate locally; and the other parasiticides considered 
heretofore in connection with the treatment of ringworm, may serve 
here also a good purpose. The author has used an ointment of thymol 
in two cases with manifest advantage, and should not hesitate in others 



624: DISEASES OF THE SKIN. 

to employ Mr. Morris's solution of the same in chloroform and oil. 
The formula for this has been already given. In other cases, the 
stimulating spirit of green soap with sulphur; finely powdered sul- 
phur, boric, acetic, and carbolic acids, or other topical applications of 
recognized value may be employed. 

\\* 1 M 1 1 resort is had to epilation, and this is essential in all severe 
Cases, the hairs should be thoroughly removed from their follicles 
over every lumpy nodule, and even over every suspicious patch cov- 
ered with scales. A zoue should be cleared about each such papule. 
The results are prompt, and in the highest degree satisfactory. 

Prognosis. — This disease is always remedied sooner or later, though 
at times tedious in its progress, and characterized by relapse. 

Precautions to be observed in the General Management 
OF Tinea Favosa and Tinea Trichophytina. — The physician, 
consulted in the case of a patient affected with either of the diseases 
thus far considered as resulting from the presence of a vegetable 
parasite, should bear in mind that they are the most highly conta- 
gious of their class. He may not only himself suffer from the 
disease which he is attempting to relieve in another, but also convey 
it to others himself, or be consulted by others of his patient's family, 
actually infected during the course of the treatment pursued. 

Generally it may be said that the hands of the physician should 
be carefully washed after each manipulation of the part, and prefer- 
ably by aid of a weak disinfecting solution. When practicable, 
infected individuals should occupy separate beds ; and the bed- 
covering, clothing, towels, toilet apparatus, and dressing or other 
materials which have been in contact with a diseased surface, should 
be immersed in boiling water before they are again employed for any 
use in common. Thin recommends covering every diseased patch, 
after the treatment appropriate to itself, with an adhesive and imper- 
meable dressing, for the sake, not of the patient, but of those with 
whom the latter may be brought into contact; and the suggestion seems 
to the author both wise and practicable. A gentleman infected with 
ringworm of the beard in a barber's shop which he has visited but 
once, will often, when directed by his physician to shave, resort to 
some other establishment, where he is well known, and where he has 
more confidence in the cleanliness of the operators. In this way he 
often thoughtlessly spreads the disease of which he is the victim. In 
his city, the author is iu the habit of sending patients who cannot 
shave themselves, to a particular barber, who, being instructed in the 
manner of shaving so as not to communicate the disease, has thus far 
failed to spread the disease in any case. 



TINEA VERSICOLOR. 625 



Tinea Versicolor. 

Tinea Versicolor is a cutaneous disease occurring chiefly upon the trunk, 
neck, and upper extremities of adults, characterized by irregularly reticu- 
lated macular lesions, yellowish or brownish in hue, over which the 
epidermis may exfoliate in delicate scales, owing to the presence of the 
microsporon furfur. 

Symptoms. — This disorder is also termed Pityriasis Versicolor, Der- 
matomycosis Furfuracea, and Mycosis Microsporia. The eruption 
occurs in the form of few or many, irregular, roundish, circumscribed 
or reticulated maculae, pin-head to small coin-sized, rarely occupying 
an area of the size of the palm or larger. In color, it varies from 
the most delicate buff or fawn shade to a reddish, deep brown, and 
even blackish hue. The surface of each lesion, when closely in- 
spected, is usually seen to be covered by furfuraceous scales. If the 
latter are not visible, slight erasion with the finger-nail will demon- 
strate the fact that the superficial layers of the stratum corneum are, 
in the site of each lesion, readily separable from the tissues beneath. 
The eruption is most common upon the anterior surface of the thorax, 
but it is also displayed upon the neck, the dorsum, aud the other sur- 
faces of the trunk, and the flexor aspects of the upper extremities 
(the hands only excepted). It is rarely seen upon the lower extrem- 
ities; still more rarely on the face; never on the hands and feet. 
The eruption is either unproductive of any sensation, or accompanied 
by a mild pruritus. Patients will usually declare, that after profuse 
sweating, bathing in warm water, or brisk friction of the surface, 
minute epidermal rolls separate from the affected area. 

Exaggerated forms of the eruption are occasionally encountered. 
In a young married woman presented to the author, who had been 
the subject of the disease for many years, the entire trunk, the axillae, 
groins, upper portion of the thighs, the neck to the level of the high 
collar worn, and the upper extremities to the wrists, were encased in 
a uniform sheet or cuirass of chocolate-tinted epidermis, in a condition 
of exfoliation in finger-nail sized lamellated flakes. Even in these 
extreme cases the tendency of the disease to avoid the surfaces ex- 
posed to the light is distinctly manifested. Unna 1 describes another 
anomalous feature of the disease, in which the maculations occur in 
annular form with a clearing centre. Rarely, also, a very few irregu- 
larly distributed maculae may be seen as the sole evidences of the 
existence of the parasite. Thus a patient may exhibit a small coin- 
sized patch on the surface of the chest, another on the shoulder, and 
possibly a third over the deltoid region of one arm. These are 
generally cases partially relieved of a more diffuse eruption. More 
commonly, the slightest manifestation of the malady is an irregular, 
vertically arranged, somewhat narrow band of lesions immediately 
over the sternum, and visible beneath the hairs of that region in the 

1 Viertelj. f. Derm. u. Syph., 1880, Nos. 2 and 3. 
40 



626 DISEASES OF THE SKIN. 

adult male, or upon the intermammary sulcus of women. The face, 
hands, palms, soles, hairs, hair- follicles, and nails, are usually exempt 
from the disease. 

Etiology. — The disease is produced by a vegetable mould discovered 
by Eichstedl in 1846, to which Robin gave the name, microsporon 
furfur. In capabilities for contagion, it is far inferior to the vegetable 
parasites already described, and illustrates well a point to which atten- 
tion has been already directed, viz., that all these fungi flourish only 
in soils suitable to their germination and fructification. Members of 
one family are said to communicate the disease occasionally, the one 
to the other, and Laueereaiix 1 reports that in this way he accidentally 
infected himself from scales collected for examination from a patient 
in hospital, and afterward unwittingly transmitted the affection to his 
wife. The author has never had personal knowledge of any instance 
of such transmission. The disease occurs in both sexes, rarely before 
puberty and after middle life, and in persons of every social condi- 
tion, irrespective of personal cleanliness. It is exceedingly common, 
more so indeed, than statistics are capable of demonstrating, inas- 
much as hundreds are annually annoyed by it who never seek pro- 
fessional advice. In the thousands of physical examinations made by 
the author with a view to the enlistment of men in the United States 
service during the late war, as also of many government pensioners 
since that date, he has been particularly impressed with this fact. 
Being concealed by the clothing and unproductive of much discom- 
fort, many persons endure its presence with complacency. 

By some it has been supposed that the fungus is particularly apt 
to select the chest of the phthisical as its habitat, a supposition doubt- 
less based upon the fact that tuberculous men and women, more than 
all others, expose the chest to the view of the medical man in order 
to permit of its auscultation and percussion. 

Pathology. — The microsporon furfur is readily recognized by the 
aid of the microscope, as it exists in luxuriant profusion upon every 
affected surface. The scales may be scraped from the skin, and at 
once examined, when innumerable clustered spores and short mycelia 
become visible; the former highly refractive and resembling in their 
circular and oval contours, droplets of oil. Their aggregation in 
clusters is distinctive of this among the other forms of cryptogamic 
vegetation. They measure 0.0023 to 0.0084 mm., while the mycelia 
vary in diameter from 0.0015 to 0.0038 (Duhring). Among the 
latter, sporophores are distinguishable, with contained conidia and 
terminal elements emerging at one extremity or the other of the 
spore-case. Both elements are more readily stained by eosine and 
methyl-violet than those of the trichophyton or of favus. 

One of the strongest arguments against the claim for the identity 
of all the vegetable parasites is furnished by the history of this inter- 
esting mould. It never by any possibility invades the hairs or the 
hair-follicles, though it may be seen flourishing at the orifice of a 

1 Tr.ntr d'Aniitomie Pathol., x<. p 265, Pari*, 1875. 



TINEA VERSICOLOR. 
Fig. 83. 



627 




Microsporon furfur. (After Kaposi.) 

follicular duct, aud even beneath a vigorous pilary growth upon the 
chest of a male subject. It avoids the light and the air ; and singu- 
larly refuses to encroach upon certain covered portions of the body, 
even preferring, in its extremest development, to linger unobtrusively 
at the neck near the verge of the collar. 

Diagnosis. — Here, as in all the parasitic diseases of vegetable 
origin, the microscope may be required to decide the diagnosis in any 
case where a doubt might arise. In its simpler manifestations, the 
recognition of the affection is very readily assured. The location of 
the eruption, its irregular reticulations, its characteristic, yellowish or 
fawn-tinted shades of color due to the nature of the fungus ; and the 
exfoliation of the epidermis which it excites by its superficial penetra- 
tion of the outer layer of the stratum corneum, producing thus a 
mealy, branny, flaky, or roll-like exuvium ; all this is significant. 
None of the chloasmata due to pigment changes in the skin, however 
much they may resemble tinea versicolor in color, share with it this 
peculiarity of desquamation. Chloasma may involve, moreover, the 
face; tinea versicolor almost never. Vitiligo may occur upon the 
scalp ; tinea versicolor very rarely. The macular syphiloderm may 
be mistaken for the disease under consideration, but when developed 
to such an extent as to rival tinea versicolor in its diffuseness, the 
syphiloderm will creep out over the face, the hands, and the feet ; 
and will be accompanied by adenopathy, alopecia, mucous patches, 
palatine hyperseniia, or furuish evidence of a polymorphic tendency. 
Often, indeed, with such an eruption, the survival of the initial 



628 DISEASES OF THE SKIN. 

sclerosis will at once betray the nature of the disease. These are 
important considerations, since in the mere matter of subjective sensa- 
tion, color, shape, and size of lesion, there may be marked reseinblauce 
between the two. The author has treated several patients with tinea 
versicolor who were suffering from syphilis; and many having the 
former disease who, from the fact of exposure, believed they also were 
infected by the latter, and yet indeed were not. These incidents 
serve to illustrate the importance of making an accurate diagnosis in 
every case of cutaneous disease. 

The most vulgar error, however, committed in this connection, is 
based upon the fancied resemblance in color between the patches of 
tinea versicolor, and either the liver itself, or the color changes which 
disease of that viscus is capable of producing in the skin. The exist- 
ence of "liver-colored" spots on the skin is hence erroneously 
attributed to hepatic disease. A remarkably comely, healthy-looking 
woman, of high social standing, who had been vainly treated for two 
years by internal remedies addressed to the liver, once consulted the 
author, with a view to the removal of large patches of tinea versi- 
color from the surface of the chest. She was completely relieved of 
her disfigurement in a single week by the employment of local 
measures alone. Few patients consult their physician for the relief 
of this disorder who have not a prejudice of similar sort. 

Treatment. — The author has always employed a single method of 
relieving tinea versicolor, for the simple reason that that one has been 
invariably successful. It is practically that given by Tilbury Fox, 
and requires merely vigorous and intelligent cooperation on the part 
of the patient. A hot bath is taken, if possible, for three nights in 
succession, and when the surface is well macerated by the hot water, 
the affected skin is resolutely scrubbed, either with the cheap yellow 
soap of the grocer, or sapo viridis in substance or tincture. When 
the disease is extensively developed, this process is aided by friction 
with the flesh-brush or a coarse towel. The skin is then washed 
clean with a surplus of hot water, the patient still remaining in the 
bath, after which the affected patch is first moistened with vinegar 
and water, or dilute acetic acid, and afterward well sponged with a 
solution of the sodium hyposulphite, one drachm (4.) to the ounce 
(32.) being usually sufficient. As a rule, the last vestiges of the 
eruption are removed with the third bathing. Should there be 
recrudescence in isolated patches, as is often the case, or outlying 
areas which have withstood the parasiticide employed, these should 
be subsequently attacked with a solution of the corrosive chloride of 
mercury, one to two grains (0.066-0.133) to the ounce (32.). Other 
measures, however, are popular with physicians, and among them 
may be named the topical use of boric, carbolic, and sulphurous 
acids; the tincture of iodine; sulphur in bath, ointment, or lotion; 
calomel in ointment ; the alkalies in baths or lotions; sulphide of 
potassium in bath ; chrysarobin, pyrogallol, tar, Wilkinson's salve, 
and the other parasiticides employed in the treatment of ringworm of 



EKYTHRASMA. 629 

the body. The inner clothing should not be worn after treatment 
till it has been immersed in boiling water. 
The following formula also is recommended : 

R . Hydrarg. chlor. corros. 9j ; 1 33 

Saponis viridis ^ij ; 64 

Spts. vin. rectif. giv; 128 

01. lavandul. f"3j ; 4 M. 

(Anderson.) 

Prognosis. — The disease can be readily relieved by simple treat- 
ment. Relapses often occur, and require to be radically treated. 
Untreated, the disease may continue for years without the slightest 
impairment of the general health. It is probable that when untreated, 
the parasite undergoes spontaneous exfoliation in advanced years, a 
period when presumably the fungus fails to find in the epidermis the 
nutriment upon which it thrives. 

Myringomycosis. 

The spores of the aspergillus, being conveyed to the external ear, 
occasionally develop there, especially if they come in contact with 
fatty substances introduced for medicinal purposes. Usually whitish 
masses can be recognized in the canal, covered with greenish, 
brownish, or blackish spots. There is usually some deafness, with a 
sensation of ringing in the ears, and at times a thin serous discharge 
from the external auditory meatus. Lowenberg 1 recommends the 
injection of dilute alcohol into the canal for the destruction of the 
mould. 

Erythrasma. 

Gr. kpvdpdg, red. 

Erythrasma is a cutaneous disorder, affecting chiefly those regions of the body 
where exposed surfaces of the skin are in contact, characterized by ery- 
thematous, rosette-shaped maculations, and due to the presence of the 
microsporon minutissimum. 

Buckhardt first described this disorder in 1859, but it received its 
name from v. Barensprung in 1862. It has since been carefully 
studied aud described by Balzer and Riehl. 

Symptoms. — The disease first appears in punctiform to palm-sized, 
roundish, definitely circumscribed maculations, presenting a sharp 
contrast in color with that of the adjacent integument. This hue 
varies somewhat according to the location of the patches. The 
younger lesions may exhibit a vivid redness over the entire maculae, 
or over their borders only. The older exhibit a yellowish or 
brownish tinge. These colors are supposed to be compounds of 
ordinary erythematous redness and yellowish or brownish discolor- 
ation of the homy layer of the epidermis. 

The maculae are circular, or rosette-shaped, or display very irreg- 

1 Gaz. Heb. d. Med. de Paris, 1880, 2me ser. xvii. p. 579. 



630 



DISEASES OF THE SKIN. 



ular"outliues. They are not raided above the general level of the 
skin to any extent, though the finger pressed over the surface can 
recognize a slight elevation of the border due to hyperaemia and sub- 
sequent moderate, fine-flour-like, furfuraceous desquamation, most 
conspicuous also at the periphery. Vesiculation and papulation do 
not occur. The colors recognized in different patches may be light 
reddish-brown, pale reddish-yellow, and light or dark orange. 

The eruption is most commonly encountered when apposed surfaces 
of the skin come in contact, such as occurs in the axillae, the groins, 
the cleft of the anus, and the regions where the scrotum touches the 
thigh. The eruption spreads very slowly and in serpiginous outline, 
until the affected surfaces are completely invaded. It is said to be 
much more chronic in its course than the other dermato-mycoses, 
lasting for months and years without apparent change. 

Etiology. — Erythrasma is produced by the growth in the superficial 
layers of the epidermis, of the fungus described below. Men are 
much more often affected than women ; children not at all. The 
youngest patient whose case is recorded was sixteen years old ; the 
oldest, fifty-five. 

Pathology. — The fungus termed microsporon minutissimum to 
which the disease is attributed, is chiefly remarkable for the extra- 

Fig. 84. 




. sal 



Microsiiorun minutissimum, from patches of erythrasma. 



ordinary delicacy and fineness of its threads and spores. The former 
are either simple cylindrical bodies of variable sizes or may exhibit 
partition septa ; they may divide dichotomously ; and may terminate 
in hooked or knobbed expansions. They are inextricably interwoven 
when occurring in lar^e masses. The largest transverse diameter is 



SCABIES. 631 

0.6 of a micromilli metre; in length, the niyeelia present the greatest 
variation. Bacteria and heaps of zooglcea are visible among the 
scales. The granules are piled into irregular heaps according to 
Burckhardt, and give a dusty appearance to the epidermal cells on 
which they lie; often the outline of these granules is indistinct. 
According to the same observer, the breadth of the mycelia is 12 1 Q0 
mm.; and the length from y 1 -^ to ^fo mm - 

Diagnosis. — From all ordinary chloasmata and pigment macula?, 
the spots of erythrasma are distinguishable by the ease with which 
the superficially embrowned epidermal layers are removed by erasion. 
Tinea versicolor is distinguished from erythrasma with greater diffi- 
culty ; but the latter occurs in different situations by preference ; its 
patches are more vividly red ; and the parasite, under the microscope, 
presents distinctive features. 

The Treatment is that of tinea versicolor ; and the prognosis|favor- 
able, subject to the disappointments arising from frequent relapses. 

La Perleche. — Under this title, Dr. Justin Lemaistre, of 
Limoges, 1 describes a contagious disease observed by himself in more 
than three hundred children of his city. It is characterized by dry- 
ness, smarting, cracking, and excoriation of the lips, the epithelium 
of which becomes blanched, macerated, and readily detached. 
Hemorrhagic and painful fissures form in the direction of the com- 
missural folds. Often plaques are visible suggesting mucous patches. 
The disease lasts for from fifteen days to a month, with possible 
recurrences which may lead to a year's suffering. 

The disease is supposed to be of parasitic origin, communicated by 
drinking from cups used by infected persons. The author attributes 
the disease to a streptococcus plicatilis which he has cultivated in 
Pasteur flasks. The microbes were originally found on the borders 
of epithelial cells of ±he lips of infected children. The parasite lives 
in stagnant water, wells, and springs in the form of a micrococcus. 
The disease is one of uncleauliness ; and readily prevented by 
appropriate hygiene. 

2. Animal. 
Scabies. 

Lat. scabere, to scratch. 

Scabies is a contagious cutaneous affection, characterized chiefly by the for- 
mation of the cuniculus, or furrow, produced by the acarus scabiei wbich 
is the cause of the disease, as also by the occurrence of several of the 
elementary lesions of the skin, accompanied by itching. 

Symptoms. — Scabies, or " The Itch," is a disease of polymorphic 
character, which may be viewed as an artificial eczema or dermatitis, 

1 Le Progres Medical, October, 1884. 



632 DISEASES OF THE SKIN. 

produced by the invasion of the itch mite. According to the extent 
to which the skin is primarily invaded by the parasite, or secondarily 

injured by the traumatism which follows severe scratching of its 
surface, will its objective symptoms differ. 

Prominent among the latter is the cuniculus, or acariau furrow, 
an elongated gallery excavated in the epidermis by the female acarus 
soon after her impregnation by the male. The latter does not enter 
the skin, but is lodged beneath the crusts or other exuvire which 
gather upon its surface. This cuniculus or furrow, is a whitish or 
yellowish, slightly arciform, linear lesion, covered with dots or specks 
of blackish aspect, representing feces of the mite, with regular parallel 
borders. It terminates at the upper extremity, by a vesicle, pustule, 
or exfoliation of the surface at the site of an infundibuliform depres- 
sion ; and at the deeper extremity, by a whitish and yellowish, 
shining and salient point, representing always the acarus. This is 
the most characteristic symptom of scabies. 

The " head" of the gallery is usually whitish, where the parasite 
first entered the skin ; and is also more elevated than the " tail," 
where the acarus rests after laying its dozen or more of eggs. At 
times, the entire cuniculus forms an elevated ridge, rather than a 
thread-like depression, with white dots along its summit. When 
the roof of the vesicle at " the head" is torn off by scratching, the 
effect is to produce a reddened spot at its site, surrounded by a 
whitish moat running around the spot to the entrance of the gallery. 

When the burrow exists, it can be most perfectly recognized in the 
interdigital spaces and on the skin of the penis, as a tangential line, 
running from a vesicle, papule, or pustule, to a distance of from one- 
eighth of an inch to an inch. It resembles a beaded, dotted, yellowish 
or blackish thread, the color being more pronounced in comparison 
with a fresh colored and washed skin, and less marked in contrast 
with a soiled surface ; being, in a soiled and subsequently washed 
integument, most conspicuous in proportion as the small puncta have 
served to entrap particles of dirt. The cuniculus may be curved, 
angular, or tortuous; and occasionally may be seen well nigh com- 
pletely covered by a bulla, pustule, or vesicle extending its entire 
length. In such cases, however, the female always penetrates beyond 
the peripheral wall of such lesion, working her gallery beyond it and 
more deeply, lest she be lifted by the exudation out of reach of the 
succulent rete where she feeds. 

Hebra points to the fact that between two parallels, one drawn 
through the nipples, and another at a short distance above the knees, 
on the anterior face of the body, can be recognized the greater part 
of the eruptive lesions in every case of scabies. 

The disease is indeed one peculiar to those classes which are the 
familiars of filth and poverty, occurring among these at all ages and 
in both sexes. As a matter of accident, it may appear, however 
rarely, in individuals of high social station. It is much more common 
in Scotland, Austria, Prussia, Sweden, Norway, France, and the 
Orient, than in this country. During the late civil war, it prevailed 



SCABIES. 633 

with relative frequency among the masses of Americans associated 
in regiments with foreigners who had been but a short time in the 
country ; and since then, seems to have steadily decreased. But few 
cases are seen annually in the public clinics of large cities, though here 
and there, chiefly among newly arrived immigrants, isolated " nests" 
of the disease are discovered. 

In consequence of the irritation produced by the parasite and the 
traumatisms of scratching this furrow, all the symptoms of acute and 
chronic eczema are presented in the region invaded. These are vesi- 
cles, pustules, wheals, small papules, hypersemia of the skin upon which 
these rest, crusts formed by dried serum, pus and blood, excoriations, 
fissures, and, in cases of long standing, pigmentation of the skin 
where the disease has existed. These lesions may coexist, several 
appearing at the same time upon the skin of an affected individual ; 
small vesicles and pustules, with perhaps a few short cuniculi visible 
upon their summits ; excoriations ; larger and longer cuniculi inter- 
spersed between inflammatory papules ; a tumid skin, evidently the 
seat of a mild grade of dermatitis ; and crusts here and there, beneath 
which male and young acari are ensconced. Such is the composite 
picture of a typical eruption in scabies. 

It will be remembered that the acarus family find nutriment, 
shelter, and all they require on the person of the individual whose 
skin they inhabit ; and there is no inducement for them to colonize 
at the instant of the first opportunity offered. The transfer of a 
male acarus alone, from one person to another, would not insure a 
generation of the young; and the unimpregnated female could not 
alone do more. As for the impregnated female, Hebra, on several 
occasions, failed to induce scabies when one such only was transferred 
intentionally to a sound skin and seen to penetrate it. Lastly, the 
eggs alone would not suffice, for these have to be nicely planted within 
the epidermis, in order to be hatched safely to maturity. In brief, 
only the more intimate contacts of the bed at night, and the applica- 
tion of nails charged with acari of both sexes, especially the young, 
are to be regarded as most effective for the transmission of the disease. 
That is one reason while nearly seven men are found to be affected 
with scabies to one woman. Women are, as a rule, more inclined 
to sleep alone, or with those only to whom they have family ties ; 
while laborers, boys, apprentices, and persons of that class, including 
those who are strangers to each other, at times occupy the same beds, 
especially in the large cities, where they are often huddled together at 
night like swine. 

The intruder may be recognized always at the terminal extremity 
of her gallery, for it is now known that she does not in her lifetime 
leave it for any purpose, as was at one time taught. The female 
acarus here shows as a minute, whitish, clearly defined dot, present- 
ing a contrast in this particular with the blackish feces in the gallery 
behind ; and may be, in a good light, by a person of some dexterity 
and fair eyesight, extracted on the point of a cambric needle, from 
her lodging-point. It is important to know that this parasite may 



634 



DISEASES OF THE SKIN 



be recognized by the unaided human eye. Its characteristic tortoise- 
like body exhibits most of its anatomical peculiarities under a glass 
enlarging the figure but one hundred diameters. 



Fig. 85. 




V 



\ ■ 



Female acarus, fecundated ; ventral surface. An ovum arrived at maturity is visible 
within the body. (After Kaposi.) 



The regions affected by the eruption are the palms (especially of 
women and children) and dorsal surfaces of the hands ; the flexor 
aspects of the wrist-joints ; the sides and roots of the fingers and 
toes ; the feet (and, especially in women, the delicate skin of the feet 
near the instep, partly dorsal, partly plantar in situation) ; the but- 
tocks (more particularly in those who are seated in the trades and 
occupations of life); the extensor faces of the joints; the belly, the 
penis and scrotum in men ; the anterior folds of the axillae ; the 
nipple and breast of women; the elbows and knees, rather than the 
popliteal space and bend of the elbow ; and the anal region. Scabies, 
prurigo, and pruritus are alike in this, that in each the face and 
posterior aspect of the body display the fewest of any lesions visible. 
In general, portions of the body subjected to constant pressure by 



SCABIES. 



635 



the clothing, as, for example, the regions pressed by the corset of the 
woman, and the waistband of the trowsers in man, are sites of predi- 



FlG 




Acarianifurrow, from the lumbar region The female acarus is visible at the terminal extremity of 
the furrow with ventral surface exposed, and containing a mature ovum ; two ova, next her, have 
been laid during the day, as the third exhibits traces of the embryo ; the twelfth exhibits a mature 
larva ; twelve empty shells are also seen ; between these the feces are represented by blackish points. 
(After Kaposi.) 

lection. In other cases, the disease is encountered in the axilla?, 
groins, and, as a matter of rare exception, over the entire surface of 
the body. 



636 DISEASES OF THE SKIN. 

The itching of scabies is occasionally severe, and has in fact con- 
ferred upon the disease its familiar English title, "the itch." This 
sensation is usually worse at night, when the parasite is rendered 
active by the heat of the body in bed, retained by the bed-clothing. 
It differs somewhat in different cases, beiug at times the cause of but 
little complaint. There is nothing characteristic, however, in the 
occurrence of this symptom, as equally severe pruritus accompanies 
eczema unconnected with parasites. 

The itching which results from the epidermic tunnelling in progress 
is often noticeably more severe than would be suggested by the 
moderate number of skin lesions visible. When these lesions (puncta, 
vesicles, pustules, blebs, papules, resulting crusts, furrows, excoria- 
tions, etc.) are found upon the hands the itching becomes so great that 
the infested person scratches also the accessible parts of the skin, where 
there were originally no acari, such as the inside of the thighs, the 
lower belly, etc., as Hebra suggests, simply because they are " handy." 
Hence it is that the picture comes to resemble that of all pruritic and 
scratched skins. 

Several artificial forms of this polymorphic affection are occasionally 
noted. In children, the face may become diseased after contact with 
the breast of the mother, or the buttocks after contact with the flexor 
aspect of the nurse's arm. Large vesicles, and even rupioid bullae, 
may result from the irritation of their tender skins. Again in sub- 
jects predisposed to eczema for any reasons, the invasion of the para- 
site in one region of the body, possibly a region of preference, may 
originate an eczema in another locality whither the parasite has not 
wandered. In other cases, the most exaggerated forms of eruption 
are seen, usually in persons of filthy habits who have long suffered 
from the malady. Thus extensive epidermal callosities form, filled 
with debris of dead parasites unable to find nutriment longer in the 
coruified rete; or extensive greenish and blackish crusts cover colonies 
of acari which survive beneath them for generations of their race. 
The nails in such extreme cases may be involved. The so-called 
Scabies Norvegica, or Norwegian itch, belongs without doubt to 
this class. As a rule, however, the disease does not advance to these 
severe grades. The parasites having gained lodgement in the skin, 
produce characteristic symptoms of the disease in the average of 
cases, but even though unrecognized, and persisting for weeks, are 
the sources of so much annoyance that treatment of some sort is 
instituted which is apt to restrict the extension of the malady, cer- 
tainly in this country, within moderate limits. Usually after lodge- 
ment is effected, a week or fortnight elapses before the first character- 
istic furrow is formed, though the pruritus is of earlier occurrence. 
The extension of the disease by the maturing and ravages of young 
acari requires a few weeks more, so that in the course of from two to 
three months, the evolution of the malady may be considered as 
complete. In the course of about three months more, the disease, 
unchecked may become generalized. 

Even the animal parasites elect the soil upon which they thrive, 



SCABIES. 637 

and indeed, after such election, thrive well or ill, according to the 
conditions present. This is not only exemplified in the matter of 
individual susceptibility, but in the conditions of health of an affected 
person. Thus in puerperal and typhoid fevers and other grave 
states of systemic disturbance, the parasites perish in the skin and 
the resulting eruption disappears; classical symptoms recurring in 
convalescence if one or more acari have survived with sufficient vigor 
to reproduce their kind. 

Etiology. — The disease is produced only by the acarus scabiei (or 
sarcoptes scabiei) and is thus contagious, the parasite being introduced 
upon the surface of one individual, mediately or immediately from 
the skin of another infested man or an animal. All persons are 
supposed to be susceptible to the disease, but the difficulty of inten- 
tionally transmitting it by contagion is greater than that of inducing 
the leech to fasten itself indiscriminately upon any given skin. The 
brief shaking of the hand or transient personal contacts of the daytime, 
are certainly in many cases quite insufficient for contagion. The 
author has repeatedly handled the skin of a patient affected with scabies 
for half an hour at a time, always with impunity ; and never hap- 
pened to know of a practitioner of medicine who suffered after the 
most careful examination of a patient. When a case is exhibited at 
-the clinic, it is minutely, and without ill results, examined by dozens 
of students. It is probable that the contacts of the night, incidental 
to the occupation of the same bed, or the use of gloves and other 
articles of apparel containing parasites or their ova, is essential to the 
transmission of the disease. 

Pathology. — The pathology of the eruption induced by the parasite 
is that of the various phases of exudation. The differences betrayed 
between scabies and all other eruptions of similar type, depend, in 
the case of the former, upon the peculiarities of the exciting cause of 
the disease. In the description of this, the acarus scabiei, I shall 
avail myself of the admirable chapter devoted to the subject by 
Kaposi. 

The female acarus, visible as a yellowish-white dot at the cul-de-sac 
of her subcutaneous gallery, and removed hence on the point of a 
fine needle, is visible to the naked eye, but best examined under the 
microscope. The body is oval, with a short projecting head and a 
convex dorsum transversely corrugated, with short spinous processes 
projecting for the most part backward, a direction largely followed 
also by the eight long bristles which are most notable at the posterior 
extremity of the trunk. The posterior portion of the dorsum also 
exhibits a series of recurved, short, hook-like projections, arranged 
circle-wise, about the ano-vaginal orifice. 

The flat ventral surface exhibits eight short claws or legs, four 
anterior and four posterior. The former are set near the head, and 
are provided each with hairs, and a long, pedunculated sucker. 
The latter are armed solely with long, straight bristles. All the 
eight have five articulations. The head is oval in shape, and pro- 
vided with four pairs of mandibles and six palpi. There are two 



638 DISEASES OF THE SKIN. 

ventral outlets; and a stomach, intestines, ovaries, muscles, and even 
mature ova can be recognized internally. 

The males are smaller than the females and fewer in number. 
They differ also in this, that the posterior extremities are provided 
with suckers and stalks, as are the anterior extremities of the female. 
Situated between these and the median line, is a horse-shoe shaped 
mass of chitine ensheathing a fork-shaped penis. 

They are said to die in the course of from six to eight days after 
copulation with the female. The latter survive from twenty to sixty 
days. 

The female alone, as already said, penetrates the epidermis. This 
act she accomplishes by inserting the head first into the tissues of the 
skin, the body disappearing- afterward, and depositing behind, in the 
course of her progression downward, from one to two eggs daily till 
from twenty to fifty have been laid. These are oval, their longi- 
tudinal axes placed transversely to the cuniculus. In the two or 
three eggs found nearest the female, only a yellowish color cau be 
distinguished; in the third to the fifth, traces of the embryo are 
recognizable; the sixth to the ninth contain larvae; and, in the 
oldest, the head and front legs can be discerned. There are six of 
these extremities when all are developed. When mature, the shell 
of the ovum is ruptured, usually between the third and sixth day, 
and the young acarus reaches the surface of the skin, either by making 
exit at the original point of entry of the mother, or by the rupture 
of the roof of the burrow. It subsequently buries itself in the skin 
for a brief time, while the process of casting its slough is completed. 
There are said to be three of these periods in its existence. Before 
the first is accomplished, the young acarus is provided with but two 
pairs of posterior extremities, two anal bristles, and ten dorsal spines. 
After the first, it is an octopod with four oval bristles and twelve 
dorsal spines. At the second, it gains two dorsal spines, and after 
the third, it possesses fourteen. The acarus survives but a few days 
when removed from the skin and immersed in liquids which protect 
it from the air, such as water, oil, etc. 

The transmission to man of the acarus peculiar to the horse, cat, 
sheep, rabbit, elephant, etc., may be accomplished; but the colony 
under these circumstances rarely thrives. The same is true of the 
human acarus when transferred to the lower animals. 

Diagnosis. — The diagnosis of scabies must rest upon the recogni- 
tion of its special features described above. There are no lesions 
peculiar to the disease save the cuniculi or furrows made by the para- 
site, and these, it will be remembered, do not appear till one or two 
weeks have elapsed after infestation. They may also be obliterated or 
concealed by excoriations when the finger-nails plough them open, or 
by pustulation and subsequent crusting when the irritation induced 
is excessive. In every well-marked case, however, cuniculi can be 
discovered, if not on the fingers, wrists, or foreams, at least on the 
penis, the breast near the nipple, or some other covered portion of 
the body. With care and little dexterity, a fine cambric needle can 



SCABIES. 639 

be then forced into the furrow well down to and a little beyond its 
remote cul-de-sac, and the fons et origo malorum be thence extracted 
and placed under the objective of the microscope. 

Next to the cuniculus, and its inmate or inmates, the two most 
important diagnostic features of scabies are, the polymorphism of the 
eruption and the sites of its most frequent occurrence. Possibly the 
latter should be named first, as the more important of the two. Few 
skilled diagnosticians would fail to entertain a suspicion of scabies in 
a case of supposititious "eczema," existing upon the fingers, wrists, 
and penis only, or on the breast of a mother, the face and buttocks 
of her infant, and the arms of its nurse. 

At the same time, it is a matter of great importance to remember 
that eczema is often attended with very severe itching; that this 
sensation may be intensely aggravated after retiring to bed at night; 
is often limited to the hands ; is not rarely characterized by inter- 
digital vesicles and pustules ; and is, indeed, in this country very much 
the more frequently encountered of the two diseases. The vulgar 
conception of scabies holds to the belief that the disease is exceedingly 
common; that every severe itching with a cutaneous exanthem is 
produced by "insects" or "worms" in the skin, and that transient 
casual contacts are abundantly capable of transmitting the offending 
parasite. Many more cases of simple eczema are supposed to be 
scabies than the reverse. There are tew villages in the country which 
cannot lay claim to an "itch," often known by a name of local sig- 
nificance. Among these may be counted the so-called "prairie itch" 
of the West. These are, as a rule, forms of eczema quite unconnected 
with the existence of a parasite, and incurable generally by the para- 
siticides too often employed to "kill" the disease. In all such 
instances, the absence of the characteristic features of scabies described 
above, the absence of a history of contagion, and the presence of that 
of an alternating relief and aggravation of the symptoms, will point 
to the real character of the malady. 

In the severe pruritic affections of the West and Northwest, which 
the reader will find described in the chapter devoted to the several 
forms of pruritus, it is noticeable that the patients are often cleanly, 
those who are careful as to the hygiene of the body. Scabies is really 
a filth disease, and is best recognized among the filthy classes. Of 
diagnostic importance is the relative proportion in frequency of cases 
of scabies to all other cutaneous affections, pruritus included, observed 
in this country. 

From the year 1878 to 1882, the statistical committee of the 
American Dermatological Association reported 58,617 cases of skin 
diseases of all kinds, and the total number of cases of scabies included 
in the list was but 665, that is 1.10 per cent. The year 1883 to 
1884 was an exceptional one as regards scabies. Out of 9329 cases 
of cutaneous disease reported from Boston, New York, St. Louis, 
Chicago, and Canada, there were 339 cases of scabies. This rela- 
tively great increase was largely due to local causes, however ; for of 
these cases Boston reported 179, and accompanied these figures with 



640 DISEASES OF THE SKIN. 

a note calling attention to the increase. It is interesting to specify- 
that of the cases collated in the year named, only 33 were seen in 
private practice, the remainder, 306, being observed in dispensary or 
public patients. 

During the succeeding year ending June 30, 1885, there were 442 
cases of scabies reported from the several districts, of which 49 
occurred in private, and 393 in public practice. This year, also, 
Bostou exhibited the largest increase, reporting three more than one- 
half the entire number of cases of scabies registered in this country, 
viz., 224. 

Treatment. — The treatment of scabies has in view the destruction 
of the parasite and the relief of the cutaneous disorder which the 
former has induced. Ordinarily the two indications are fulfilled at 
the same time. In such cases, the destruction of the parasite is 
followed by relief of the resulting cutaneous lesions; and the skin, 
freed from the burrowing acari, is no longer tormented by the 
scratching which in extreme cases is not only irresistible but an 
important element in the aggravation of the lesions. In other cases, 
however, the resulting eczema or dermatitis persists after the removal 
of the original cause of the disease, and demands special attention. 
Care should always be had to avoid treating the delicate skin of the 
infant with the severer remedies efficacious upon the thicker integu- 
ment of the adult. 

Sulphur, in all its forms and in various combinations, has long 
held the highest esteem in the treatment of the disease. Other 
remedies, however, of acknowledged efficacy are employed with satis- 
factory results, most of them owing their usefulness to the strong odor 
which they emit. Among these may be named carbolic acid ; petrol- 
eum ; naphthol ; the oils of cloves, cinnamon, rosemary, and mint ; 
tar; balsam of Peru and balsam of Tolu; styrax ; staphysagria ; 
Vleminckx's solution, heretofore described ; and sapo viridis. 

Sulphur is commonly employed in the form of an ointment, one to 
two drachms (4.-8.) to the ounce (32.), firmly, thoroughly, and care- 
fully rubbed, first into the affected patches, especially between the 
individual fingers, (or toes), about the wrists, over the palm and 
dorsum of the hand, into the axillae, about the nipples, penis, buttocks, 
or other invaded parts ; and finally over the cutaneous surface in 
general, the head alone excepted. If no severe eczematous complica- 
tions exist, the inunction is well preceded by a warm soap, or soft 
soap and water bath. But in the event of such complication, the 
bath should be deferred as decidedly injurious in the inflamed condi- 
tion of the skin. 

This first inunction is preferably performed at night, after which 
the patient retires to his bed enveloped in woollen underclothing, or 
wrapped in a blanket. It is neither wise nor necessary to induce 
sudation by these measures, for the skin is best retained in simply a 
greasy condition, unmacerated by sweat. In England, it is customary 
to bathe on the ensuing morning, but it is preferable to defer the 
latter till the cure is complete, however disagreeable the condition of 



SCABIES. 



641 



the integument may be to the sufferer. The sulphur inunctions are 
thus repeated for three successive nights, a thorough warm soap and 
water bath being finally employed for the purpose of cleanliness. 
The clothing meantime should be either thoroughly disinfected with 
sulphur, immersed in boiling water, or subjected in a stove or furnace 
to a dry heat capable of destroying all acari and ova which might 
adhere to it. 

In France, the routine treatment of scabies is always preceded by a 
thorough friction for twenty minutes with soft soap, special attention 
being as usual directed to the invaded areas. This is at once 
followed by a bath in warm water, during which the surface is also 
thoroughly scrubbed for from thirty minutes to an hour. Lastly, 
the parasiticide is well rubbed on for fifteen minutes, the patient 
redressed in the underclothing (disinfected during the progress of the 
bathing) and the final cleansing of the skin with water is practised 
within twenty-four hours. 

When a resulting eczema demands attention, it is to be treated in 
accordance with the general principles considered in the chapter 
devoted to that subject. In such case the dusting-powders, the 
oleated lime-water, the zinc, diachylon, and even more stimulating 
ointments, may be employed with advantage. Generally, after a 
vigorous course of external treatment with sulphur, the patient 
should be instructed to defer any further topical applications to the 
skin for a week or more, in order to test the efficaciousness of the 
method pursued. 

One of the following formulae may be substituted for the ordinary 
sulphur ointment : 



R. Sulphur, flor. 


3xij ; 


48 




Potass, subcarb. 


3yj; 


24 




Adipis 


5 ix ; 


288 


M. 


Hardy's modification of Helmerich's ointment. 




R . Styracis liq. 


f3j; 


4 




Petrolei ) 
01. olivse j 


[aa f^ss ; 


16 




Balsam. Perav. 


f^ijss ; 


10 




Spts. sapon. virid. 


f3v; 


20 


M. 






(Kaposi.) 


R. Potass, sulphuret. 


3v; 


20| 


Sapon. alb. 


3xx; 


80j 


01. oliv. 


f3iv; 


16! 


01. thym. 


gtt. xv ; 


l| M. 
(Jadelot.) 


R. Sulphur, sublim. 1 
Balsam. Peruv. j 


aa 3ss ; 


2 ! 


Adipis 


Ei; 


32, M. 


For use especially in the 


scabies of children. 





Duhring. ) 



Hebra's modification of Wilkinson's salve, Vleminckx's solution, 
and the balsam of Tolu are employed for the same purpose. 



642 



DISEASES OF THE SKIN. 



Kaposi's naphthol formula is : 

R. Naphthol 15 parts; 

Sapon. virid. 50 parts; 

Cret. alb. pulv. 10 parts ; 

Axung. 100 parts; M. 

McCall Auderson much prefers, on account of its pleasant aroma : 



R. Styracis liquid. 

Adipis 
Melt ami strain. 






M. 



or Sehultze's modification of Pastav's formula 



R. Styracis liquid. 
Spts. rectincat. 
01. olivae 

Ft. liniment. 



fou; 
f3j; 



M. 



Prognosis. — Scabies is an entirely curable disease, even after per- 
sistence for long periods of time. When, however, complications 
exist, or severe eczema continues after the efficient action of a para- 
siticide, the patient may experience some delay before attaining 
complete restoration to health. 



Demodex Folliculorum. 



Fig. 81 



This parasite, known also as the steatozoon, or acarus folliculorum, 
was discovered by Simon, in 1842. It is a microscopic creature in 
the form of an elongated and jointed worm, with 
head separated from the thorax, and eight legs, four 
on a side, each with three articulations, and termi- 
nating in three small hooklets. The posterior ex- 
tremity of the body is a vermiform appendage, 
terminating in a conical point. 

The demodex is found long after birth upon the 
free surface of the skin, those parts particularly 
where the sebaceous glands are large, and on patients 
affected with acne or seborrhcea oleosa, as well as 
upon those free' from all evidence of disease. It is 
encountered also in the substance of the comedo 
plug, where at times from five to twenty may be 
discovered in a single follicle. It is, however, in no 
case the source of disease. A demodex, which is 
considered to be a variety of that discovered upon 
the skin of man, infests dogs, mice, and other lower 
animals ; and may be, in the latter, the source of 
disease characterized by furuncular lesions, abscess, 
and even fatal results. None of these parasites 
are, however, known to be transmissible to man. 



Demodex t'olliculorur 



ANIMAL PARASITES. 643 

Pulex Penetrans (Rhinocoprion Penetrans, Sarcopsylla Westwood). 

The sand-flea is a minute, brownish-red, egg-shaped parasite which 
penetrates the skin of man and of the lower animals, including rats 
and mice. It is encountered chiefly in tropical countries, but is said 
also to exist in higher latitudes, even in some of the southern of the 
United States. Fecundated females only attack the skin, in man 
usually about the toes or near the nails, entrance being effected with 
scarcely painful pricking sensations. In the course of from five to 
ten days, a painful oedema with pustulation follows, occasionally 
accompanied by a lymphangitis or severer symptoms in the form of 
gangrenous abscesses. These sequelae are said to result from the 
distention of the ovary of the parasite, which may exceed fivefold 
the original dimensions of the insect. The treatment of the disease 
is the extraction of the flea by the aid of a heated needle, whereby 
it is simultaneously destroyed. The resulting wound is often also 
cauterized. 

Filaria Medinensis (Filaria Sanguinis, Guinea Worm). 

This parasite is encountered in the tissues only of those who have 
resided in tropical latitudes, more particularly in Egypt, Persia, 
India, and Arabia. It is occasionally encountered in other countries 
after introduction by affected individuals. When it attacks the skin, 
it forms a painful, oedematous, furuncular or bullous lesion, which 
bursts ; and in the fluid contents exuded, a portion of the worm 
becomes visible. Often the systemic conditions which accompany 
this lesion are grave. Febrile, convulsive, or septicemic phenomena 
may then be followed by fistulous or gangrenous results in the seat of 
the disease. 

It was long claimed that the parasite entered the skin from 
without, but there is reason to disbelieve this assertion. Observers 
have lately demonstrated the fact that the parent worm contains, in 
that part of the body which is appended to the head, thousands of 
minute worms contained in a sarcocliform envelope. These measure 
0.05 by 0.2 mm., each exhibiting a thickened cephalic extremity 
without a buccal aperture, and a ointed caudal termination. It is 
impossible for such a creature to penetrate the skin by the accidents 
usually assigned as the occasion of its introduction ; for example, by 
bathing in infested water, and walking upon surfaces where the para- 
sites abound. It is much more reasonable to conclude that the latter 
are ingested, either with the food, or, more probably, with the water, 
and that from the alimentary canal they find their way to the other 
structures which they attack. They can certainly traverse the 
blood-vascular channels. The worm has been photographed in situ, 
in the bloodvessels where it was discovered. It is possible, however, 
that the parasites may be, in rare instances, introduced into the skin 
directly through solutions of continuity produced in walking, bath- 
ing, and other occupations, when the foot or ankle is accidentally 



64-1 DISEASES OF THE SKIN. 

abraded, or where indeed there lias been a preexisting ulcer or sore. 
Manson 1 believes that the parent Maria inhabits the lymphatic trunks ; 
and reports a case of lymph-scrotum in which a long slender worm, 
resembling catgut in appearance and of the thickness of a medium- 
sized horse-hair, was found tilled with embryos in different stages of 
development. After the removal of about two inches of the parasite, 
the worm was broken. It has also been recognized in the sac of the 
tunica vaginalis affected with hydrocele. 

The mosquito is -aid t<> act as a carrier; sucking the filaria with 
the blood of an affected person, it afterward deposits the ova or 
embryos, which have meantime hatched, in the water where it lays 
its own eggs. These embryos are then swallowed with the drinking- 
water by another victim ; and so the cycle of disease is completed. 
It is a nocturnal parasite. During the day the filarial lie dormant at 
some point in the victim's circulation, but at night they sally forth 
and rove the current of the blood the night long. 

The parent worm, fully developed, may measure two feet or more 
in length ; and, being usually packed fuli of young, it is a matter of 
great importance not to injure it in any efforts made for the purpose 
of its extraction. Forbes Dick 2 describes the four methods chiefly 
employed for the purpose of obtaining relief, as operating on the 
principle, either to " stink, coax, suck, or pull the worm out." The 
first is usually accomplished by the aid of assafoetida poultices, and 
is the least desirable of all. A combination of the others is pre- 
ferred, the warmth, moisture, and protection afforded by the poultice 
first attracting the worm to the surface. When this result is obtained, 
an incision is made, and usually a foot or more of the worm is at 
once liberated. According to Dick, when the worm can be felt at 
two or more places, the point for incision is at the third part of its 
anterior extremity, which is always furthest from the heart of the 
patient. After this the worm is carefully wound about an aneurismal 
needle or similar implement, and traction very gently made upon it 
for from ten to fifteen hours. If it cease to yield to this force, the 
traction should never be increased, lest the parasite seize the adjacent 
tissues with its mouth. Suction by the natives is accomplished 
through trumpet-shaped tubes. 

Cysticercus Cellulosae. 

Cysticerci have been recognized in the skin and subcutaneous 
tissues by Rokitausky, Lewin, Guttmanu, Schiff, Ferreol, Duguet, 
and other observers. In such cases, one or several roundish, firm, 
elastic, cutaneous or subcutaneous, pea to walnut-sized tumors, isolated 
or disseminated, unproductive of pain, project from the general level, 
and are enveloped by au unaltered integument. They may remain 
in this condition without change for years ; and may accompany 
cysticerci of the brain and other portions of the body, productive of 

i Lancet, 1880, p. 1<). "- British Medical Journal, 1880, p 207. 



ANIMAL PARASITES. 645 

the serious disturbance of the economy which such invasion may 
determine. If the skin tumors be opened and their contents exam- 
ined, the parasite will be recognized as an ampulliform sac, with a 
cephalic appendage, reentrant or projecting, and provided with four 
suckers and a coronal of hooklets. By no external characteristics 
could such tumors be distinguished from others of similar size and 
external appearance. Only in the rare case of nervous complication, 
could a suspicion arise based upon the real character of the disorder. 
Respecting this matter, however, the diagnostician is in no worse 
position than when called upon to recognize cysticerci of the viscera. 
On more than one occasion, cysticerci of the liver have been dis- 
tinguished during life, and subsequently removed by operative 
procedures. 

The diagnosis is from gumma, lipoma, epithelioma, and sarcoma. 
The first occurs only in the syphilitic; the second has a peculiarly 
uneven surface and firm feeling ; the third is largely facial in situa- 
tion ; and the last is of a plainly malignant character and relatively 
rapid career. 

Echinococcus. 

Weyl and Geber state that this parasite, not mentioned in derma- 
tological treatises, is found often in the human skin. Of 336 cases 
reported by Davaine, the parasite occurred thirty times in muscular 
and subcutaneous tissues, more often in women than in men. The 
vesicles produce a disagreeable sensation of tension, and undergo 
fatty or other metamorphosis after the death of the encapsulated 
parasite, which usually occurs in from one to two years. Explora- 
tion of the superficially seated fluctuating tumor, covered by unaltered 
integument, usually demonstrates its nature. 

Distoma Hepaticum. 

Kiichenmeister (1. c.) reports three instances in which the embryos 
of the large liver fluke were encapsulated in subcutaneous tissue. 
The tumors were painful or painless and occurred on the head, trunk, 
and extremities. 

Leptus. (Leptus Autumnalis, Harvest Bug.) 

This is a minute, reddish, or yellowish-red insect of the family of 
the trombidse, visible to the naked eye, and found in summer and 
autumn clinging to bushes and grasses. It is found both in this 
country and in Europe. It attacks man only after its accidental 
location upon the skin, where it perishes in the course of a few hours. 
In such situations, however, it induces considerable irritation, betrayed 
in erythematous, urticarial, papular, and eveu eczematous symptoms, 
accompaniedby pruritus of various grades. It may be seen in the 
skin as an orange-reddish or brick-reddish point, which represents 
often the body of the insect, its head being buried in the aperture of 
a follicle beneath. Examined after extraction, it is seen to have a 



64:6 



DISEASES OF THE SKIN 



relatively large cephalic extremity. It has a short, cylindrical, and 
conical hanstellum, composed of fused double maxillae; and two 
strong, hooked, five-jointed palpi, which can be rolled up. There 
are also two hatchet-like mandibles. It has a well-rounded body 




Fig. 80. 




Leptus. (After Kuchenmeisteb.) 



Leptus autuninalis (harvest bug). 



0.3558)mm. long, and 0.32 mm. broad, provided with three pairs of 
legs. It is found upon the lower limbs particularly, but also upon 
the scalp and every other part of the body. According to Duhring, 
children are particularly liable to its encroachments. The disorder 
is relieved by the application of a little balsam of Peru in olive oil, 
carbolated oil, spirit of camphor, or other mild stimulant or parasi- 
ticide. 

Kriptoptes Monunguiculosis. 

Fig. 90. 




ANIMAL PAEASITES. 647 

Acarus hordei is the name given by Weyl and Geber to the larva 
of a mite that annoys laborers in barley. It is yellowish-white, 
oblong or oval in form, averaging 0.022 mm. in length. There is a 
protrudible tubular haustellum, enclosed by serrated mandibles. On 
each side are five-jointed palpi. There are four pairs of feet ; two 
on the cephalo-thorax ; two, abdominal in situation; all articulated 
to the epimeres. The tarsus of the first pair terminates in hooked 
claws ; the others have haustellum disks on stems. Between the 
first and second pairs are swinging clubs, indicating the larval condi- 
tion. 

Dipterous Larvse in and beneath the Human Skin. 

There is no dipterous insect peculiar to man alone, but a number 
of cases are on record where the ova of several species of oestrus 
have been deposited in the skin, and larvse been subsequently formed. 
The oestrus bovis/or gad-fly, is the most common of these. Usually 
after the ova are deposited by the insect, a painful swelling occurs 

Fig. 91. Fro. 92. 




c a 

CEstrus. a, the larva, natural size ; 6, some Larvse removed from the body of a child. Of 

of the segments seen under a lens, and show- the exact size, after several days in alcohol ; 

ing the lines of minute projection ; c, and a, as seen from side ; 6, as seen from beneath. 

d, the terminal ends of the insect. (After 
Abraham ) 

which may change its place from one point to another. AYhen sup- 
puration is induced, the larvse can be removed by pressure upon the 
boil. Walter Smith, 1 of Dublin, has lately described such a case, 
where the swelling upon the ankle of a girl twelve years old, moved 
to the elbow, and there discharged a white grub nearly an inch in 
length. Birdsall 2 has described a specimen sent him from Gaboon, 
on the West Coast of Africa, in which two worms escaped from 
between the middle and the ring fingers of one hand ; another 
workman having had a similar accident occur upon the leg. The 
fly whose ova had been deposited in these two cases, was said to 
attack the gorilla ; and the Pawnees, a tribe of Indians engaged in 
capturing these animals, were reported as being very commonly 
troubled in the same way. The worms sent to Dr. Birdsall were 

1 See Report of Internat. Med. Congress, Arch, of Derm., January, 1882. 

2 N Y. Med. Record, March 18, 1882, p. 298. 



648 DISEASES OF THE SKIN. 

respectively one-fourth and one-half of an inch in length, and about 
one-eighth of an inch in thickness. 

Abraham, of Dublin, has also examined and reported upon a 
similar case, the specimen having been sent to the editor of the 
London Medical Press and < focvlar, from Portsalon, Letterkenny. 

Several specimens illustrating these accidents have been sent to the 
author from neighboring States. The larvae represented in the sub- 
joined sketch were removed from the body of an infant in Nebraska. 
The muscidse (flesh, house, stable, dung, and other flies) have defec- 
tive maxillae, and are, therefore, unable to wound the uninjured skin. 
The pregnant female seeks, therefore, to deposit her ova where the 
larvae, equally unprovided with developed jaws, can most readily 
secure nutriment. Hence, open wounds and the tender skins of 
newly born infants when exposed in the summer season, are liable 
to become the depots of such ova. 

The ova of other species of muscidse and cestridae (according to 
Geber, of the former, Lucilia Caesar, in America ; Stominis Calcitrans, 
in Africa; and Sarcophila Wohlfati, in Russia; of the latter, 
Dermatobia Noxalis, Cutrebra, and Hypoderma) deposit ova or larva? 
in the skin by their special apparatus for puncture, occasionally also 
the hatched larva works its way unaided from the epidermis to the 
subcutaueous tissue. Severe cases are reported from Texas, where 
larva? have been expelled in great number from the nares after 
inhalation of chloroform. 

Ixodes (Wood-tick). 

Several species of ticks are recognized, such as the Ixodes 
Humanus, Ixodes Bovis (cattle-tick), Ixodes Americanus, Ixodes 
Marginatum, Ixodes Uxipunctatus, and the Ixodes Eicinus 
(wood -beetle), the last-named being more common in Europe. In 
this country they are found in wooded districts, especially those 
where pine and fir trees are growing. The female attacks the skin 
by thrusting into it her beak, armed on either side with a maxillo- 
labial projection having recurved booklets, the mandibles also pre- 
senting similar obstacles to the forcible extraction of the head. After 
suction of the blood from beneath, the body of the tick swells to 
the size of a pea or small bean, and may remain for several days in 
this position. At such times the parasite may be mistaken for a 
small pedunculated tumor. Forcible attempts at extraction of the 
intruder are liable to detach the mandibles from the body, and thus 
leave them as the source of future irritation, and even disagreeable 
inflammatory symptoms, in the site of the punctured wound. By 
applying over it a drop of the spirit of turpentine or benzine, the 
head is spontaneously retracted, and the body falls from its position. 
The soldiers on the plains of our own country, accomplish the same 
end with the juice of tobacco. The sensation produced at the moment 
of the insertion of the beak of the insect, is said to be so trifling as 
often to pass unnoticed. 



PEDICULOSIS. 649 

Pediculosis. 

Lat. pediculus, a little foot. 

Pediculosis is a contagious affection, characterized by the presence of lice 
upon the skin and hairs, by the wounds inflicted by the parasites, and by 
the scratching which the resulting pruritus excites. 

This disorder is also termed Phtheiriasis, Morbus Pediculosis, aud 
Lousiness. 

Symptoms. — Lice belong to the order, rhynchotta; subdivision, 
parasitce; family, pediculidce. They are apterous, provided each with 
two eyes, and have an oral appendage capable of both inflicting 
wounds and producing suction. The lice infesting the human body 
are recognized as belonging to three varieties, those of the head, of 
the body, and of the pubes. Of the disorders to which they give rise 
it may be said in general, that the lesions presented differ somewhat 
according to the region invaded, the multiplicity of the intruders, 
and the length of time during which their ravages have been inflicted. 
Such lesions, however, are those which have been already studied in 
connection with eczema, urticaria, and the similar disorders resulting 
from external irritation. Their special peculiarities in pediculosis, 
are owing solely to the nature of the exciting cause and the mode of 
its operation. 

Pediculosis Capillitii (Parasite, the Head Louse). 

The head louse is usually of a grayish color, but differs slightly 
with the hue of the hairs over the part which it frequents. Its head 
presents indistinctly the outline of a trefoil, and 
is provided with two hairy antennae, each of five 
articulations, and two eyes. Its thorax is rela- 
tively narrow, with six tracheal stigmata and 
three hairy legs on either side, the latter pro- 
vided with tarsal hooklets. The abdomen is 
divided into seven segments, defined by blackish 
indentations on either side. The males are 
fewer and smaller than the females, and pre- 
sent upon the dorsum an ano-genital orifice 
and a large conoidal penis and testes. The 
females are provided with ovaries, oviducts 
which terminate in a vagina having a ventral Pedi ^ lus » .capimtii - male. 

.„ .. . <=> ' O 1 (After Kuchenmeister.) 

orifice, and an anal aperture in the terminal 

abdominal segment. Coupling is performed with the male beneath. 
The ova or "nits" are whitish bodies of oval contour, which are 
glued to the hairs by a cylindriform sheath of chitine, which com- 
pletely encases the circumference of each filament. They are deposited 
in series, as the female traverses the hair from its insertion to its 
distal extremity, so that the oldest are in general the nearest to the 
scalp. The young escape from the ova in from three to eight days, 




650 



DISEASES OF THE SKIN. 



Fig. 94. 



and arrive at maturity in from eighteen to twenty days. A single 
female can, according to Kaposi, lay fifty eggs in six days, and thus 
in eight weeks have an entire progeny of five thousand lice. 

Head lice usually limit their habitat to the scalp, though, rarely, 
in elderly men with long hair reaching to a full beard, they may 
encroach upon the latter. They are found upon every portion of 
the scalp, but find the region of the greatest protection upon the 
occiput. They infest children and adults of both sexes, hut are best 
furnished with lodgement in the scalps of girls and women covered 
by long and luxuriant hairs. 

The lesions observed upon a scalp thus inhabited, vary according 
to the age and vigor of the colony; and are few or numerous, discrete 
or confluent pustules or bulla? ; surfaces excoriated by scratching and 
oozing with serum, pus, or blood : crusts varying in character 
according to the nature of the desiccated exudate aud sebaceous 
matters. Often the picture presented is a 
conglomerate of an artificial eczema and 
seborrhcea. 

The ova, or "nits," are usually abundant 
upon the hairs of an infested head, and will 
scarcely escape the attention of a close ob- 
server. They are not to be mistaken for the 
exfoliated, epithelial, and fatty plates seen in 
seborrhcea sicca, disseminated among the 
hairs, and often perforated by hairy fila- 
ments, since the former are firmly glued in 
position, and resist the bristles of the hair- 
brush. The peculiarly nauseating odor also 
of the louse-infested, pustule- and crust- 
covered scalp is not to be confounded with 
that perceived in favus of the same region. 

In exaggerated cases, the post-cervical 
ganglia express, by their increase in size, 
the degree to which the local irritation has 
been pushed. The itching is usually severe, 
and, in cases of long persistence in children, 
may produce the usual systemic symptoms 
of prolonged local irritation. Children and 
patients of impoverished health and with 
poor hygienic surroundings, are thought to 
exhibit the disease in severer grades than 
others ; but this, if indeed a fact, must be 
at least in part due rather to the more favor- 
able conditions for the development and 
multiplication of the parasites, which are 
presented in filth accumulation and lack of 
cleanliness. In the public charities of large cities, children are pre- 
sented every week affected with pediculosis capillitii, who come from 




p\ 



of tlic head-louse attached to 
hair. (After Kaposi.) 



PEDICULOSIS. 651 

the very lowest social grades of population and from the filthiest 
quarters. Among these it cannot be observed that the general health 
of the patients is a factor of weight in the severity of the affection. 

The diagnosis of pediculosis capillitii is a matter of considerable 
importance, however simple of accomplishment, since many cases of 
supposed "pustular eczema of the scalp" have been treated vainly by 
one physician with internal remedies addressed to the systemic vice 
assumed to be responsible for the disease which another has relieved 
after the discovery of a few head-lice. The hairs should always be 
raised and separated, the scalp carefully inspected, and the presence 
of any parasites, and especially ova or "nits" fastened to the hairs, 
ascertained. Whether the lice have preceded or followed the eczem- 
atous state (and each of these conditions may be noted) is a matter of 
minor importance. 

The indications in the treatment of pediculosis capillitii are the 
destruction of all parasites with their ova, and the relief of the 
induced inflammatory condition of the scalp. Generally, the removal 
of the former is followed by the spontaneous disappearance of the 
latter. 

For the destruction of the lice, the most popular remedy, in this 
country certainly, is ♦petroleum [not kerosene], pure or with equal 
parts of the balsam of Peru, which gives it a more agreeable perfume, 
poured over the scalp in quantity sufficient to cover it without overflow 
upon the brow, temples, and neck. It should be rubbed in with a piece 
of white (undyed) flannel. At the end of from twelve to twenty-four 
hours the lice are destroyed, and the ova rendered incapable of devel- 
opment. This treatment is followed by a thorough shampoo with 
tincture of soap, or toilet soap and hot water; after this operation 
the tender scalp may require a bland unguent, such as vaseline, or a 
small quantity of scented castor oil, either pure or in combination 
with spirits of wine. Kaposi employs petroleum as a parasiticide in 
combination with olive oil and balsam of Peru : five parts of the 
first, two and a half of the second, and one of the third. Cutting 
the hair of women and girls is quite unnecessary, as patience and 
gentleness with the use of the comb will finally disentangle the most 
matted masses after the lice have been destroyed. Other remedies 
are employed locally for a similar purpose, of which the most 
popular are staphysagria, one drachm (4.) of the powdered seeds to 
the ounce (32.) of vaseline, but especially in decoction ; the tincture of 
cocculus Indicus; carbolic acid in oil or water; sabadilla; the ethereal 
oils; and mercurials in ointment and solution, including the mercuric 
oleates. In cases where but a few parasites have found their way 
to the scalp, and that recently, nothing more is requisite than a 
careful use of the fine-tooth comb, scrubbing the scalp with a strongly 
scented alcoholic perfume, and a final bathing with soap and hot 
water. 

The ova adhering firmly to the hairs can be removed by soda or 
borax lotions, alcoholic solutions, or dilute acetic acid, which are 



652 



DISEASES OF THE SKIN, 



solvents for the gluey material by which the 
place. 



nits 



are secured in 



Pediculosis Corporis l Parasite, the Body Louse). 

The parasite in this disorder inhabits exclusively the clothing 
worn next the body, and is hence often designated as the Pedi- 
CULUS VESTIMENTI. In anatomical peculiarities it resembles the 
pedioulus capillitii already described, being, however, larger in size, 
the females also larger than the males. The thorax is separated from 
the abdomen, the latter being hairy, yellowish at the margins, and 
provided with eight segments. The eyes are black, and very promi- 
nent in both sexes ; and the periods requisite for the maturing of 
the ova and young are those named respectively in connection with 
head lice. In color they vary slightly from a dirty-white to a light 
grayish hue, when uudisteuded with blood. 
In the reverse of this last-named condition, 
they may be recognized as having a dull 
reddish or purplish color, when they are 
also more indolent in their movements. 
They measure 2 to 3 nim. in length, and 1 
to 1.5 mm. in breadth. The female lays 
from seventy to eighty eggs, from which the 
young are produced in from three to eight 
days, and are capable of reproduction in a 
fortnight more. 

They inhabit the seams of undergarments, 
where their ova are also deposited, but in 
coarse woollen or flannel shirts they find 
sufficient shelter in the meshes of the mate- 
rial of which the clothing is made. This 
they leave temporarily, solely for the pur- 
pose of obtaining nutriment from the skin 
of their host, and hence are not often recognized upon the free 
surface of the integument. Upon rapid removal of the clothing of 
an infested individual, a few may occasionally be encountered, hastily 
seeking a place of refuge, though this is rather the exception to the 
rule. It thus may happen that a louse-bitten patient may not exhibit 
the true source of his troubles to his physician after a recent and 
complete change of clothing. The greater then the importance of 
being able to recognize the clinical features of the malady in the 
absence of the parasite. This is comparatively easy to one who has 
made himself familiar with the symptoms of the disorder. 

The manner in which the louse is enabled to supply itself with the 
blood of man has been carefully studied by Swammerdam, Landois, 
Schjodte, and Tilbury Fox. The last-named author has summarized 
the observations of the others, and the results he gives may be briefly 
described as follows : 

Swammerdam's original view that the louse is not provided with 




Pediculus corporis — female. 
(After Kuchenmeister ) 



PEDICULOSIS. 653 

mandibles by which it can inflict a wound, but with an haustellum 
by which the blood is sucked up to the head of the parasite, is con- 
firmed by Schjodte. This observer, examining the head of the louse 
from behind with reflected light, discovered that the parts of the 
head resembling mandibles in appearance, were really situated beneath 
its skin. He applied to the integument lice which had been pre- 
viously starved, and watched each as with retracted limbs, arched 
back, and head inclined obliquely downward, it repeatedly projected 
forward and retracted throngh the extreme end of its head a " small, 
dark, narrow organ," by which it was finally firmly held in place. 
A triangular blood-red point soon became visible in front of the eyes, 
rapidly and alternately contracting and dilating, and followed by 
energetic peristalsis of the gastro-intestinal tract. If the head then 
be cut off in front of the eyes, and the haustellum carefully extracted, 
the latter can be recognized as a brownish protrusion, armed with 
terminal recurved hooks, from which depends a delicate membranous 
tube varying in length. 

"It seems that the mouth is like that in the rhynchotta generally, 
but differs in the circumstance that the labium is capable of being 
retracted into the upper part of the head, and has a fold in it when 
so retracted. In order to strengthen this part, a flat band of chitine 
is placed on the under surface ; and it is thinner in the middle in 
order that it may bend and fold a little when the skin is not extended 
by the lower lip. The latter consists of two hard lateral pieces, of 
which the fore ends are united by a membrane, so that they form a 
tube, of which the internal covering is a continuation of the elastic 
membrane on the top of the head. Inside its orifice are a number of 
small hooks, which assume different positions according to the degree 
of the protrusion ; and if this is pushed to its highest point, they 
form a collar of hooks curved backward like barbs. The pediculus 
first inserts its labium into a sweat pore and protrudes the lip. When 
the hooks get hold of the parts around, then the first pair of seta? 
(the real mandibles transformed) are protruded, and these are toward 
the point invested by membrane so as to form a closed tube, from 
which again is exserted a second pair of setae or maxilla?, which form 
a tube and end in four small lobes placed crosswise. The whole 
forms a membranous tube, along the walls of which retiform man- 
dibles and maxillae are placed as long narrow bands of chitine. This 
tube can be lengthened or shortened at pleasure." 

This explanation of the mode in which the louse attacks the skin, 
is probably true of each of the varieties which infest the human 
body. Fox well suggests that the invaded follicle, after the with- 
drawal of the haustellum, becomes the seat of a circumscribed hemor- 
rhage. None of the anatomical peculiarities described above will, 
however, completely explain, it seems to the author, the characteristic 
pruritus of pediculosis corporis, for it can scarcely be questioned that 
it is not merely at the moment of attack or penetration that the 
suffering of the victim is greatest. The pruritic condition of the 
louse-wound persists, indeed usually attains its maximum, after the 



65-i DISEASES OF THE SKIN. 

withdrawal of the pediculus, and is without doubt greater than that 
awakened by merely mechanical puncture of the epidermis. Any 
one who will compare the skin of a louse-infested patient with one 
who has been subjected to the acupuncture process employed among 
the lower classes of Germans, and by them known as " baunseheid- 
tismus," can convince himself of this fact. 

The lesions seen on the skin thus invaded are proportioned, as in 
pediculosis capillitii, to the size and age of the colony of parasites. 
Excoriations, usually linear, occasionally circumscribed, varying in 
depth and length, radiate irregularly from each louse wound, and 
may be commingled with minute papules, transitory wheals, or, in 
rare, exaggerated cases, with the typical signs of diffuse eczema. All 
are produced by scratching in order to relieve the pruritus. Crusts, 
more often composed of desiccated blood, rarely of serum or pus, 
minute and capping the wounded follicle, or linear and coextensive 
with the excoriations produced by the scratching, are generally con- 
spicuous. In older cases these lesions are followed by the usual 
sequel, pigmentation, the latter being a partial indication of lousiness 
which has been long tolerated. 

In this country, it is rare to note the severe and intense forms of 
the malady resulting from long-continued neglect of the skin, which 
occur in Germany. In such cases, dermatitis, rupioid crusts, fur- 
uncles, abscesses, carbuncles, and ulcers form, bequeathing to the 
skin serious disorders, which may persist for weeks after the clothing 
has been freed from lice, and finally leave a deep-tinted, diffuse 
pigmentation of the surface, suggesting that of the negro or of the 
patient affected with Addison's disease. 

The diaguosis is a matter of importance. Patients will visit 
physicians, claiming that they have suffered from a " humor of the 
blood," who have been swallowing drugs for a long period of time, 
in the vain hope of obtaining relief, with lice, at the very moment of 
uttering the complaint, crawling over their persons. Even those of 
good social position aud habits of cleanliness, will occasionally suffer 
after the accidental contacts in the street- or railway-car, the hotel, 
the theatre, or other places of public resort. There are certain points 
to be carefully noted in this connection. Excoriations over the nucha, 
about the shoulders, loins, buttocks, and external faces of the thighs, 
all visible at the same time, are highly suspicious symptoms ; as an 
eczema, when equally diffuse, is sure to be accompanied at some 
point by perfectly classical features ; and generalized pruritus is 
exceedingly rare, its localized varieties concerning chiefly the regions 
about the mucous outlets of the body. There is a picture highly 
suggestive of pediculosis exposed to the eye when the trunk of an 
infested patient is viewed from behind. The lesions are more discrete, 
more irregularly distributed, aud more intermingled with long scratch- 
marks, reaching, for example, quite over the point of one shoulder, 
than in most disorders with which this could be confounded. Here 
and there minute blood specks tell a significant tale. The author has 
occasionally the opportunity to exhibit patients at the clinic, with 



PEDICULOSIS. 655 

syphilodermata interspersed among characteristic lesions of pedicu- 
losis corporis ; and often the students themselves in such cases point 
out the particular symptoms referable to the separate disorders 
present. 

In private practice it is usually advisable, for obvious reasons, to 
secure the corpus delicti before informing the sufferer of the nature 
of his or her complaint. In the case of male patients, it is well to 
take a position in the rear, and when the underclothing is drawn 
well up from the shoulders, a careful scrutiny of it may be made 
while the applicant for relief supposes that attention is directed 
instead to his person. 

The treatment of the disorder concerns largely the clothing. The 
latter requires immersion in boiling water, or may be wrapped in 
paper and subjected to a high temperature in an oven, 160°-175° F., 
sufficient to destroy the lice and their ova. In case of recurrence of 
the malady, the clothing is to be again subjected to the same process. 
Usually the resulting irritation of the skin promptly subsides. 
When several members of one family suffer, all clothing worn must 
be subjected to similar treatment. If the skin has been unusually 
tormented by scratching, warm alkaline baths will afford some com- 
fort, and may be followed by a bland unguent or one of the dusting 
powders. For immediate use, before the clothing can be rid of the 
intruders, a parasiticide ointment can be ordered as recommended by 
Duhring, prepared by adding two drachms (8.) of freshly powdered 
staphysagria to the ounce (32.) of hot lard, strained and cooled. The 
surface of the skin may also be anointed with carbolic acid dissolved 
in oil or water. 

Pediculosis Pubis (Parasite, the Pubic Louse). 

In this disorder the genital region is chiefly involved, though in 
exceptional cases all the hairy portions of the skin may be invaded, 
including the eyebrows, eyelashes, axillae, and the moustache, beard, 
hairy chest, and hairy legs of the male. The body of the pubic 
louse is <snialler than either of those described above. Its head is 
also attached more closely to its thorax, having a shape which is 
compared to that of a violin. The thorax is not distinctly separated 
from the abdomen and of the six stout legs that spring from it, the 
second and third pair are conspicuously powerful, and armed with 
relatively large hooks at the tarsal extremity. The resemblance of 
the latter to the claws of a crab, has given to this creature the 
common name of "crab-louse." The lateral abdominal indentations 
are much less distinct than in the other varieties; and the blackish 
marginal marks of the latter are here scarcely apparent. The abdo- 
men is also much elongated, having a more rounded contour, and 
being provided on its lateral borders with eight short conical feet, 
terminating in bristles. It is also distinguished from the others of 
its family by the length of its anal bristles, and by the peculiar shield- 
shaped carapace which covers nearly one-half of the dorsum. The 



656 DISEASES OF THE SKIN. 

male is 0.8 and 1. mm. long, and 0.5 to 0.7 mm. in width, being 
thus from 1. to 1.5 mm. smaller than the female. 

The pubic louse is much more inactive than the others, and does 
not ordinarily escape its pursuer. It buries its head deeply in a fol- 
licular orifice, and steadies itself in this position, where it may remain 
for some time, by grasping the adjacent hairs with its short and 
powerful claws. A moderate degree of force is required for its 
dislodgement from this favorite position, and when removed its grasp 
of the hair to which it clings is so firm that the latter usually slides 
for its entire length through the claw of the louse. Occasionally 
they may be found creeping over the skin or clinging to hairs at a 
distance from the surface. The pyriform ova are smaller than those 
of the head louse, though having a similar color ; and are, like the 
latter, attatched to the hairs by a firm chitiuous glue. 

Pubic lice are usually acquired during the contacts incidental to 
the sexual act; and are hence more frequently encountered among 
adults, but may, without any question, 
Fig. 9G. be, more rarely, transmitted mediately 

by occupation of beds and covering 
which have been used by infested per- 
sons. They are thus, though very 
rarely, found in children of both sexes. 
The lesions induced are those pro- 
duced by the wounds inflicted by the 
parasites and by consequent scratching, 
though the latter is rarely intense. In 
a few cases, one may see a severe eczema 
follow the ravages of the lice, but in 
such event the complication is chiefly 
owing to , unnecessarily severe self- 
treatment of the disorder, patients 
Pedicuius pubis. (After schmarda.) being often morbidly anxious in their 
efforts to rid themselves of the pests. 
The diagnosis of pediculosis pubis is between eczema and pruritus 
genitalium. The disease last named is, in both sexes, accompanied 
by itching, and that often of intense grade, but when this is diffuse 
and symmetrical in distribution, it is not limited particularly to the 
hairy parts. Eczema of the genitals is not often produced by para- 
sites of that region, and may be readily recognized by its character- 
istic features. Both disorders are often indeed limited to symmetrical 
patches upon the side of the scrotum or one labium. The discovery 
of the parasite, however, in pediculosis pubis, is always essential, and 
requires merely careful inspection and a good light. The lice may 
be recognized either at or near the point of implantation of the hairs, 
which latter also display ova except in very recently infested indi- 
viduals. The reddish excrement of the parasites mingled with 
scratch-marks and excoriated papules of small size, may also be 
observed. Patients are often made aware of their condition by a 
sensation of crawling over the parts. Scratching of the pubic 




PEDICULOSIS. 657 

region in adults of both sexes, should awaken some suspicion of the 
disorder. 

The disease is commonly treated by the topical application of 
mercurial ointment, which is a disagreeable and rather filthy medica- 
ment for this locality. The ten per cent, oleate may be substituted 
for it, or, even preferably, corrosive sublimate in solution, three to 
four grains (0.266-32.) to the ounce. Petroleum and olive oil with 
the balsam of Peru, in the proportions given above in connection 
with the subject of pediculosis capillitii, is an effective combination. 
Staphysagria, carbolic acid, cocculus indicus, or one of the other 
substances used in the disorders occasioned by the animal parasites, 
may be substituted if desired. 

It is usually better to defer bathing till the remedy selected for 
the destruction of the lice has been applied on several occasions, after 
which a warm water and soap ablution will commonly end the 
trouble. It is needless to clip the pubic hairs. Should an eczema- 
tous disorder remain, it requires appropriate treatment, including hot 
bathing and the blander unguents. 

Pediculi and Acari transferred to Man from the Lower 
Animals rarely thrive in such uncongenial soil, but as a matter of 
exception, occasionally survive such transfer. Thus Goldsmith, 1 of 
Vermont, reports the case of a woman affected with intense pruritus, 
who after sweating profusely observed numbers of pigeon- or hen- 
lice emerging from the sweat-pores. Megnin 2 reports similar cases 
under the title Prurigo Dermanyssique, the dermanyssus avium 
or gallinee being the acarus infesting domesticated fowls. The dis- 
order is said to be at times epidemic iu the vicinity of aviaries and 
pigeon-cotes, but is always of trifling severity. 

Cimex Lectularius (Acanthia Lectularia, Bugs, or Bed-bugs). 

Strictly speaking, the bug is not a parasite of man, but finds its 
congenial habitat in the bed, bedding, bed covering, walls and 
floors of apartments occupied by persons of both sexes and all ages. 
It infests also furniture, including chairs, sofas, and the cushions of 
seats occupied in public vehicles and hotels. From the cracks, 
crevices, seams, folds, or other protected points where it has found 
lodgement, it emerges usually at night, for the purpose of securing its 
nutriment in the blood of its victims. It is a pest as ancient as the 
day in which Dioscorides wrote, since he described it. 

The insect has a rusty or reddish color, this differing slightly 
according as it is or is not distended with blood. It is an apterous 
member of the order CiMidDiE; and is provided with a blunt- 
pointed head, broadly attached to the thorax; two long slender 
antenna?; and a three-jointed haustellum capable of projection and 

i Louisville Med. News, Dec. 31, 1881, p. 3'20. 

2 Les parasites et les maladies parasitaires chez l'homme, les animaux domestiques, etc., Paris, 
1880. 

42 



658 DISEASES OF THE SKIN. 

retraction beneath the head. There are three pairs of long slender 
legs by which it is enabled to accomplish rapid movements, two 
thoracic and four abdominal. The abdomen is broad, flattened, and 
oval in shape, with nine segments. The parasite emits a disgusting 
odor, which is much more distinct when it is crushed. 

The wound inflicted by the bug is accomplished with or without 
the consciousness of its victim, who in the former case is made aware 
of a transitory prick or sting. Soon after, decidedly pruritic burning 
or stinging sensations are experienced ; and the wound becomes the 
seat of an urticarial wheal. The lesion then, examined soon after 
the infliction of the wound, is seen to be small pea- to bean-sized, and 
in the form of an elevated and circumscribed "button" or papulo- 
tubercle, either whitish iu the centre, or exhibiting there also the 
hyperemia which distinguishes its peripheral zone. After it has 
begun to subside and lose its acute features, which may not occur for 
several hours if it be irritated by rubbing or scratching, a minute 
reddish puncture may be seen marking the original site of the wound. 

The lesions are usually multiple even when but a single assailant 
has been present, the insect taking apparent delight in obtaining its 
nutriment from several distinct points upon one surface. In this 
way at times its course upon the integument may be for a short 
distance traced. In cases where the pests are numerous, as in filthy 
dwellings, prisons, ships, and barracks, and when infants have been 
attacked, the resulting eruption is often greatly masked by the 
scratching and resulting excoriations of the surface. In this way 
vesicles, pustules, crusts, purpuric blotches, and even skin infiltra- 
tions may be found, instead of the rosy or light reddish typical 
wheals of recent cases in patients with fair clean skins. The diag- 
nosis is a matter of importance, and upon it may hang a professional 
reputation. Physicians are often consulted respecting these lesions 
by patients who believe themselves to be suffering from " humors," 
exanthemata, and even syphilis. The insect attacks the parts of the 
body to which access is easy as the patient sits or reclines on the back 
or side, including the buttocks, thighs, shoulders, loius, and neck, in 
that order of frequency, rather more largely than the legs, much less 
frequently the scalp, face, and genitalia. The eruption is not to be 
confounded with urticaria ab ingestis, which is more apt to be sym- 
metrical in disposition. 

It is best relieved by the topical application of spirits of camphor, 
alcohol, weak carbolated lotions, or solutions of boric acid, one 
drachm to the pint. Untreated, it disappears spontaneously when 
the source of the disorder is removed. The most effective treatment 
is by prophylaxis, with soap and hot water, of all accessories of the 
dwelling-house inhabitable by the insects. Once discovered to be 
present, infested furniture should be scrubbed in all its crevices with 
a saturated solution of corrosive sublimate in alcohol, and bed- 
clothing immersed in boiling water. 

Other INSECTS, which may persistently or only occasionally 
attack the human skin, are: the mosquito and gnat (Culex Pipiexs), 



PEDICULOSIS. 659 

midges (Tipulid^e, Simulia); bees (Apes Mellifer^e) ;• wasps 
(Vespid^e), and fleas (Pulex Irrltans). 

Pulex Irritans. 

The Flea which specially attacks man is a brownish-red insect, 
having a laterally compressed body, an oral haustellum, serrated soft 
mandibles, a tongue sheathed in an inferior labium, and a pair of 
labial, four-jointed palpi. Each of the triple segments of the thorax 
bears a pair of five-jointed, double-clawed legs. The male is 2 to 5 
millimetres in length, and 1 to 2 in breadth, the female being nearly 
twice that size. The female deposits her eggs in any fissure, crevice, 
or fold of garment or furniture which may be accessible, from which 
the larvae are produced in a week. The nympha is enfolded in a 
cocoon, but the mature insect only preys upon man. According to 
Geber, it injects an irritating fluid into the skin at the moment of 
attack. The lesion it produces is a hsemorrhagic punctum, followed 
by a transitory hypersemia and a hemorrhagic exudation which may 
persist for a few hours. 

Culex Pipiens, etc. 

Mosquitoes, midges, etc., produce, by their bites or stings, various 
cutaneous lesions, including urticarial wheals, papules, ecchymoses, 
and in rare cases even ecchymomata. Those produced by the flea 
are found more often on the legs, neck, or other covered portions of 
the body ; those of the midge and mosquito on the face, hands, and 
exposed parts ; though, when numerous and voracious, these insects 
will penetrate the clothing for the purpose of obtaining blood. 
Severe eruptive lesions are often seen in this country on the faces and 
extremities of infants and children exposed during the night to the 
incursions of these marauders. They are usually treated locally by 
aqua ammonise or the spirits of camphor. 

The bodies of immigrants newly arrived during the summer season 
in America, from countries where the mosquito is either rare or does 
not exist, often present singular and even formidable evidences of the 
attacks of these insects. The skin, totally unaccustomed to such 
depredations, and quite unprotected, will often be found greatly 
swollen, aud of a light reddish hue, suggestive of erysipelas. Here 
and there bulla? are conspicuous, which add to the resemblance to the 
last-named disease. The features, in consequence of the tumefaction, 
vesiculation, and papulation, may be so swollen as to present a con- 
spicuous deformity, and the forearms, and even the arms, seem 
greatly increased in size from the same cause. The feet and legs also 
may be, in the unconsciousness of sleep, exposed in hot weather to 
the depredations of these marauders, and in the same way the back, 
buttocks, and, rarely, even the genitalia present the same signs of 
inflammation. The matter of chief moment is the correct diagnosis 
of such cases, as many patients seeking relief under such circum- 
stances have been mistakenly treated for disorders with which they 
were not affected. 



BIBLIOGRAPHY. 



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On the Treatment of Diseases of the Skin, with an analysis of eleven 

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A Practical Treatise upon Eczema, including its lichenous and impeti- 
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A Treatise on Diseases of the Skin. London, 1887. 

Auspitz (Heinrich). System der Hautkrankheiten. Wien, 1881. 
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Die Hautkrankheiten. Erlangen, 1859. 

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Bazix (E). Lecons theoriques et cliniques sur les Affections generiques de la 
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Affections cutanees de nature arthritique et dartreuse. Paris, 1868. 

Behrexd (F. J.). Ikonographische Darstellung der nicht-syphilitischen 

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1883. 
Biesiadecki (A.). Pathologie und Therapie der Hautkrankheiten. Von 

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Bumstead and Taylor. Pathologv and Treatment of Venereal Diseases. 

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1828. 
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sur les Maladies cutanees. Paris, 1874. 
Depres ( Armand). Traite theorique et pratique de la Syphilis, ou infection 

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Dowse (Thomas S.) On some Diseases of the Skin which are produced by 

derangements of the Nervous System. London, 1880. 
Dchrixg (L. A.) A Practical Treatise on Diseases of the Skin. Third edi- 
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Fournier. Lecons sur la Syphilis etudiee plus particulierement chez la 

femme. Paris, 1873. 
Fox (Tilbury). Skin Diseases; their description, pathology, diagnosis, and 

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BIBLIOGRAPHY. 661 

Fox (Tilbury) and Fox (T. O). Epitome of Skin Diseases, with Formulae 

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Fuchs (C. H.). Die Krankhaften Veranderungen der Haut, etc. Gottin- 

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Gamberini (Pietro). Manuale delle Malattie Cutanee. Milan, 1871. 
Gaskoin (George). On the Psoriasis, or Lepra. London, 1875. 
Gibert (C. M.). Manuel des Maladies speciales de la Peau. Paris, 1834. 
Guibout (E.). Lecons cliniques sur les Maladies de la Peau. Paris, 1876. 
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Hardy. Lecons sur les Maladies dartreuses. Troisieme edition. Paris, 

1868. 
Haus. Die Krankhaften Veranderungen der Haut, etc. Braunschweig, 

1884. 

Traite des Maladies de la Peau. Paris, 1886. . 

HEbra. Handbuch der Speciellen Pathologie und Therapie. Erlangen, 

1860. 
Hebra und Kohn. Handbuch der Speciellen Pathologie und Therapie. 

Erlangen, 1870. 
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Erlangen, 1872. 

Handbuch der Speciellen Pathologie und Therapie. Erlangen, 1874. 

On Diseases of the Skin, including the Exanthemata. New Syden- 
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Heitzmann. Microscopical Morphology of the Animal Body. New York, 
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Hillairet et Gaucher. Traite th6orique et pratique des Maladies de la 
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Hunt (Thomas). A Guide to the Treatment of Diseases 3f the Skin. Lon- 
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Jullien (L.). Traite pratique des Maladies Veneriennes. Second edition. 
Paris, 1886. 

Kaposi. Syphilis der Haut und der angrenzenden Schleimhaute. Wien, 
1873, 1874, 1875. 

Pathologie und Therapie der Hautkrankeiten. Dritte verb. u. verm. 

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Keyes (E. L.). The Venereal Diseases, etc. New York, 1880. 

Kopp. Die Trophoneurosen der Haut. Wien, 1886. 

Kuchenmeister. On Animal and Vegetable Parasites of the Human Body. 

London, 1857. 
Lancereaux (E.). Traite historique et pratique de la Syphilis. Paris, 

1874. 
Leonard (0. Henri). The Hair; its growth, care, diseases, and treatment. 

Detroit, 1880. 
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1878. 

A Handbook on the Diagnosis of Skin Diseases. New York, 1879. 

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Milton (J. L.). The Pathology and Treatment of Diseases of the Skin. 

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Morris (Malcolm). Skin Diseases, including their definition, symptoms, 
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Neumann (I.). Handbook of Skin Diseases. Translated from the second 
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Lehrbuch der Hautkrankheiten. Dritte Auflage. Wien, 1873. 

Piffard (H. G.). A Treatise on the Materia Medica and Therapeutics of 

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An Elementary Treatise on Diseases of the Skin. London and New 

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Piffard (H. G.) axd Fox (G. H.). Cutaneous and Venereal Memoranda. 

New York, 1877. 
PLUMBE (SAMUEL). A Practical Treatise on the Diseases of the Skin. Lon- 
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Profeta (G.). Trattate della Malattie Cutanee. Palermo, 1881. 
Rayer (P.).- Train' th6orique et pratique des Maladies de la Peau. Paris, 

1835. 
Remy (A. C). Recherches histologiques sur l'anatomie normale de la peau 

de l'homme. Paris, 1878. 
Robinson (A. R.). A Manual of Dermatology. New York. 1884. 
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London, 1885. 
ScHWIMMER (Ernst). Die Neuropathischen Dermatonosen. Wien und 

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Squire (Balmanno) A Manual on the Diseases of the Skin. London, 

1868. 

The Pharmacopoeia of the British Hospital for Diseases of the Skin, 

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Startin (J. J.). Lectures on Parasitic Diseases of the Skin. London, 1881. 

Sturgis (F. R.). The Student's Manual of Venereal Diseases. New York. 
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Van Buren and Keyes. A Practical Treatise on the Surgical Diseases of 
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Van Harlingen. Chapter on Diseases of the Skin in A System of Surgery 
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Handbook of Skin Diseases. Phila. 1884. 

Willan-Bateman. A Practical Synopsis of Cutaneous Diseases. London, 
1813. 

Wilson (Erasmus). Lectures on Dermatology; delivered in the Roval Col- 
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On Diseases of the Skin, a System of Cutaneous Medicine. Sixth edi- 
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Zeissl (H.). Lehrbuch der Syphilis und der mit dieser verwandten ortlichen 

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Hautkrankheiten. Leipzig, 1883-1884. 



I N D E X. 



\ CANTHIA lectularia, 657 

A Acari from lower animals, 657 
Acarus folliculorum, 120, 642 

hordei, 647 

scabiei, 633 
Achorion Schonleinii, 599 
Acid mixture, Startin's, 114 
Acne, 319 

artificialis, 319 

atrophica, 320 

cachecticorum, 320 

diagnosis, 323 

etiology, 322 

hypertrophica, 320 

indurate, 320 

papulosa, 321 

pathology, 323 

punctata, 321 

pustulosa, 321 

rosacea, 329 

diagnosis, 331 
etiology, 330 
pathology, 330 
prognosis, 333 
symptoms, 329 
treatment, 331 

sebacea, 107 

symptoms, 319 
treatment, 323 

varioliformis, 321 

vulgaris, 321 
Aconite eruption, 179 
Acrochordon, 454 
Actinomycosis, 561 
Acute purulent oedema, 205 
Addison's disease, 362 

keloid, 409 
Adenoma, 461 
Ad'enome sudoripare, 567 
Ainhum, 495 
Albinismus, 423 

symptoms, 423 
Albinoes, 423 
Aleppo evil, 202 
Alkaline baths, 80 

spirit of soap, 80 
Alopecia, 429 

areata, 435 

diagnosis, 437 



Alopecia areata, etiology, 436 
pathology, 437 
prognosis, 439 
symptoms, 435 
treatment, 437 
congenital, 429 
furfuracea, 433 
diagnosis, 434 
etiology, 434 
pathology, 434 
treatment, 434 
neurotica, 440 
pityrodes capillitii, 433 
premature, 430 
presenile, 430 
senile, 430 

pathology, 431 
treatment, 431 
Alphos, 221 
Alveolar sarcoma, 577 
American Dermatological Association, 

classification of, 93 
Anaesthesia, 591 
Anatomical tubercle, 386 
Anatomy of the skin, 17 
Anderson's dusting powder, 158 
Anginose scarlet fever, 136 
Angioma, 464 

cavern osum, 467 
diagnosis, 466 
etiology, 468 

pigmentosum et atrophicum, 466 
pathology, 466 
treatment, 466, 468 
Angiomyoma, 463 
Anidrosis, 101 

treatment, 102 
Aniline rash, 173 
Animal parasites, 631 
Anthem ata, 57 
Anthrax, 198, 206 
diagnosis, 200 
etiology, 199 
pathology, 199 
prognosis, 201 
symptoms, 198 
treatment, 201 
Antipyrine eruption, 179 
Apes melliferse, 659 



664 



INDEX. 



Argyria, 363 

Armenian bole, 82 
Arnica rash, 17:; 
Arrectores pllorum, 32 
Arsenic, 74 
Arsenical eruption, 179 

habit, 231 
Arteries, 27 
Arthritic diathesis, 6o 
Asiatic pills, 75 

Asphyxia of the extremities, 188 
Aateatosis, 128 

symptoms, 1 28 

treatment, 129 
Asthma and eczema, 2<12 
Atheroma, 126 
Atrophia cutis, 444 

maculosa et striata, 445 

pilorum propria, 440 

senilis, 444 

unguis, 443 
Atrophy of hair, 429 

of hair of head, undescribed form 
of, 440 

of nail, 443 

of skin, 444 
Atropia eruption, ISO 
Auspitz's classification, 91 



BALDNESS, 429 
Barbadoes leg, 412 
Baths, 79 
Belladonna eruption, 180 

rash of, 139 
Benzoate of sodium rash, 185 
Benzoinated lard, 285 

sebum, 285 
Biskra bouton, 202 
Boils, 195 

Borax eruption, 185 
Boric acid eruption, 180 
Black-head, 119 
Black herpes, 213 

measles, 143 
Blanching atrophy of skin, 44(3 
Blebs, 53 

Bleeding stigmata, 593 
Bloody sweat, 106 
" Bromidia" rash, 187 
Bromidrosis, 102 

symptoms, 102 

treatment, 103 
Bromine eruption, 180 
Bronson'a classification, 91 (note) 
Bucnemia Tropica, 412 
Bug, bed, 657 

harvest, 645 
Bugs, 657 

Bulb of the hair, 37 
Bulkley's liquor picis alkalinus, 286 



Bulla?, 53 

haemorrhagicae, 354 
Burmese ringworm, 611 
Burns, 176 

treatment, 176 



pACHEXIE pachydermique, 595 
\J Cacotrophia folliculorum, 367 
Cadaveric infection, pustules from, 

201 
Callositas, 374 

Callositas of hands with unusual com- 
plication, 375 
Calorimeter, 90 
Calotte, 602 
Calvities, 429 
Calx sulphurata, 77 
Cancer, 561 
Cancer en cuirasse, 573 

films, 573 

globes, 567 

hard, 573 

lenticular, 573 

melanotic, 574 
Cancer-" nests," 567 
Cancer of connective tissue, 573 

of extremities, 566 

of genital organs, 565 

of head, 564 

of lip, 565 

pigmented, 574 

scirrhous, 573 
Cancroid, 447 
Canities, 427 

etiology, 428 

pathology, 428 

symptoms, 427 

treatment, 428 
Cannabis Indica eruption, 181 
Carbolic acid, 77 
Carbuncle, 198 
Carcinoma, 561 

diagnosis, 569 

etiology, 566- 

melanotic, 574 

pathology, 567 

pigmented, 574 

prognosis, 572 

treatment, 570 
Carron oil, 158 

Causes of diseases of the skin, 60 
Caustics, 87 
Cement-substance, 25 
Chafed skin, 156 
Chagres fever, 362 
Chancre, 498 
Chancrelle, 544 
Chancre, simple, 544 

soft, 544 

vaccination, 151 



INDEX. 



665 



Chancroid, 544 
Charbon, 198, 206 

Cheiro-pompholyx, 105 

Cheloid, 447 

Chicken-pox, 146 

Chilblains, 177 

Chloasma, 361 

pathology, 364 
symptoms, 361 
treatment, 364 

Chloasma uterinum, 361 

Chloral-camphor, 87 

Chloral eruption, 181 

Chromidrosis, 103 

Chronic erysipelas, 190 

Chrysarobin, 77 

Cicatrices, 56 

Cicatrix, 449 

diagnosis, 451 
etiology, 451 
pathology, 451 
treatment, 451 

Cimex lectularius, 657 

Cimicidse, 657 

Cinchona eruption, 184 

Claret-stain, 465 

Classification, 90 

Clavus, 378 

Cod-liver oil, 76 
eruption, 181 

Coil-glands, 40 

Collodion, 84 

Columnae adiposse, 21 

Columns, fat, 43 

Comedo, 118 

diagnosis, 121 
double, 119 
etiology, 119 
extractor, 89 
pathology, 120 
symptoms, 118 
treatment, 122 

Condyloma, 381, 511 

Confluent variola, 143 

Congelatio, 177 

Congenital syphilis, 521 

Consecutive lesions, 53 

Copaiba eruption, 182 

Copper-nose, 417 

Corium, 21 

Corn, 378 

Corn-salves, 379 

Cornu cutaneum, 379 

Corpuscles, Meissner, 31 
Pacinian, 30 
tactile, 31 
Vater, 30 
Wagner, 31 . 

Cortex of hair, 38 

Cosme's paste, 570 

Cosmoline, 81 



Cow-pox, 149 

Crab-louse, 655 

Crusta lactea, 109 

Crustse, 54 

Crusts, 54 

Cubebs eruption, 182 

Culex pipiens, 658, 659 

Cundurango eruption, 182 

Cuniculus, 632 

Curettes, dermal, 88 

Cutaneous hemorrhages, 353 

pruritus, 581 

punch, 90 
Cuticle, 24 
Cutisector, 89 
Cutis testacea, 110 
Cylindroma, 567 
Cyst, 124 
Cysticercus cellulosee, 644 



DANDRUFF, 107 
Dartric myoma, 463 
Dartrous diathesis, 65 
Deep epithelioma, 563 
Defluvium capillorum, 429 
Delhi boil, 202 
Demodex folliculorum, 642 
Depilatories, 403 
Derma, 21 
Dermal curettes, 88 
Dermanyssus avium, 657 
Dermatalgia, 590 
Dermatitis, 171 
calorica, 175 
exfoliativa, 240 
diagnosis, 242 
etiology, 242 
pathology, 242 
prognosis, 242 
treatment, 242 
exfoliativa infantum, 242 
gangrsenosa, 188 
herpetiformis, 218 

symptoms, 219 
Kaposi, 466 
medicamentosa, 178 
multiformis, 218 
papillaris capillitii, 338 
traumatica, 172 
venenata, 172 
Dermatological instruments, 89 
Dermatomycosis furfuracea, 625 
Dextrine pastes, 82 
Diabetes and eczema, 304 
Diabetides genitales, 304 
Diagnosis, general, 66 
Diet, in diseases of the skin, effects of, 

63 
Digitalis eruption, 182 
Digiti mortui, 593 



INDEX. 



Dipterous larvae, G47 

Diseases of connective tissue, 404 

epidermal and papillary layers, 366 

pigment, 422 

sebaceous glands, 107 

the skin, 95 
Dissection tubercle, 386 
I >istoma hepatieum, 645 
Donda Ndugu, 421 
Donovan's solution, 75 
•' I >riving in " cutaneous diseases, 78 
" Driving out" cutaneous diseases, 78 
Dyes, 421) 

''Dying" of feet and hands, 593 
Dysidrosis, 105 



ECCHYMOMATA, 354 
Ecchymoses, 50, 354 
Echinococcus, 645 

Ecphyma mollusciforme, 454 
Ecthyma, 345 

diagnosis, 346 

etiology, 346 

pathology, 346 

symptoms, 345 

treatment, 347 
Eczema, 252 

acute, 260 

and asthma, 262 

chronic, 260 

diagnosis, 266 

erythematosus, 253 

etiology, 261 

fissum, 259 

intertrigo, 259 

lichenodes, 254 

local varieties, 291 

madidans, 258 

marginatum, 605 

of anus, 305 

of beard, 300 

of breast, 307 

of ears, 298 

of extremities, 308 

of face, 294 

of genitals, 302 

of hands and feet, 310 

of lids, 299 

of lips, 296 

of nails, 313 

of nipple, 307 

of nostrils, 297 

of scalp, 291 

of tropics, 314 

of umbilicus, 308 

papulosum, 254 

pathology, 264 

prognosis, 290 

pustulosum, 257 

rhagadiforme, 259 



Eczema rubrum, 258 
sclerosum, 259 
solare, 314 
squamosum, 259 

symptoms, 252 

treatment, 27:; 

tuberculatum, 578 

verrucosum, 259 

vesiculosum, 256 
Electrolysis in removal of hairs, 401 
Elementary lesions, 4!i 
Elephantiasis, 412 

Arabum, 412 

diagnosis, 415 

etiology, 414 

Graecorum, 549 

lymphangiectatica, 471 

pathology, 414 

prognosis, 416 

symptoms, 412 

treatment, 416 
Elephant leg, 412 
Ephelis, 360 
Ephidrosis, 95 
Epidermis, 24 
Epilating forceps, 88 
Epilation, 602 
Epithelial cancer, 562 
Epithelioma, 562 
Erectores pilorum, 32 
Ergot, 77 
Erysipelas, 188 

ambulans, 189 

chronic, 190 

diagnosis, 192 

etiology, 191 

pathology, 192 

prognosis, 194 

symptoms," 188 

treatment, 193 
Erythanthema syphiliticum, 521 
Erythanthemata, 57 
Erythema annularis, 159 

bullosum, 160 

caloricum, 154 

diphtheriticum, 160 

figuratum, 159 

gangrenosum, 154 

idiopathic, 153 

intertrigo, 156 

diagnosis, 157 
etiology, 156 
symptoms, 156 
treatment, 157 

iris, 159 

marginatum, 159 

multiforme, 159 
diagnosis, 162 
etiology, 161 
pathology, 161 
prognosis, 162 



INDEX. 



667 



Erythema multiforme, symptoms, 159 
treatment, 162 

nodosum, 159 

papulatum, 160 

papulosum, 160 

simplex, 153 

diagnosis, 155 
treatment, 155 

symptomatic, 154 

traumaticum, 153 

tuberculatum, 160 

tuberculosum, 160 

urticatum, 160 

variolosum, 140 

venenatum, 154 

vesiculosum, 160 
Erythematous syphilide, 504 
JEry theme centrifuge, 473 
Erythrasma, 629 

diagnosis, 631 

etiology, 630 

pathology, 630 

symptoms, 629 

treatment, 631 
Etiology, general, 60 
Exanthemata, 129 
Excoriations, 65 
Exfoliative dermatitis, 240 
Expansions and fissures of hairs, 442 
External treatment, 79 



FAT canals, 43 
columns, 43 
Eat, subcutaneous, 20 
Fats and oils, 81 
Favus, 597 

squamosus, 598 
Feigned disease of the skin, 154 
Fetid sweat, 102 
Fibroma, 452 

diagnosis, 455 

etiology, 454 

pathology, 454 

prognosis, 456 

symptoms, 452 

treatment, 456 
Fibromyoma, 463 
Fibrosarcoma, 577 
Fibrous cancer, 573 
Filaria medinensis, 643 

sanguinis, 643 
Fish-skin disease, 390 
Fissures, 55 
Flea, 659 
Follicle, hair, 35 
Follicular vulvitis, 305 
Forceps, epilating, 89 

grappling, 89 
Fowler's solution, 75 
Frambcesia, 419 



Frarnbcesioid condylomatous syphilo- 

derm, 510 
Freckles, 154, 360 
French measles, 133 
Friction, effects of, 62 
Frost-itch, 588 
Fungous foot of India, 495 
Furfuraceous desquamation, 54 
Funjnculosis, 195 
Furun cuius, 195 

diagnosis, 197 

etiology, 195 

pathology, 196 

prognosis, 198 

symj)toins, 195 

treatment, 197 



GAD-FLY, 647 
Galacticlrosis, 106 
Galactorrhea, producing intertrigo, 157 
Gangrene foudroyante, 205 
Gangrenous dermatitis, 187 
General diagnosis, 66 

etiology, 60 

prognosis, 71 

symptomatology, 48 

therapeutics, 73 
German measles, 133 
" Giant wheals," 51, 164 
Glands, coil, 40 

sebaceous, 39 

sudoriparous, 40 

sweat, diseases of, 95 
Glossy fingers, 407, 446, 593 
Glycerine, 81 
Glycerolates, 81 

Squire's, 289 
Glycerole of lead, 81 
Glyceroles, 81 
Granular layer, 26 
Granuloma fungoides, 578 

sarcomatodes, 578 
Green soap, spirit of, 80 
Grutum, 124 
Guinea worm, 643 
Gum pastes, 82 
Gutta rosea, 329, 417 



H^EMATIDROSIS, 106 
Haemophilia, 357 
Hair-dyes, 429 
Hair-follicle, 35 
Hairiness, 398 
Hairs, 33 
Hard cancer, 573 
Harvest bug, 645 
Head louse, 649 
Hebra's classification, 91 
diachylon salve, 284 



668 



INDEX 



Hebra's oriental lotion, 328 

Bpiritus saponis alkalinus, 80 
"Hedge hog "tikin, 391 
Heliotrope rash, 174 
Helmerich'a ointment, ii41 
Hemiatrophia facialis, 407 
Henle's layer, 36 
Hereditary syphilis, 521 
Heredity, 64 # 

Herpes, 208 

circinatus bullosus, 219 

facialis, 208 

gestationis, 212, 219, 349 

iris, 159. 211, 219 

labialis, 208 

phlyctenodes, 219 

praeputialis, 209 

progenitalis, 209 

symptoms, 208 

treatment, 210 

zoster, 212 

diagnosis, 217 
etiology, 215 
pathology, 215 
symptoms, 212 
treatment, 217 
Herpetic diathesis, 65 

diseases, 208 
Hide-bound skin, 406 
Hireuties, 398 
Hives, 163 
Horn-pox, 142 
Horns, 379 
Hornv laver, 27 
Hot baths, 79 

" Humor of the blood," 529 
Hutchinson's teeth in inherited syph- 
ilis, 525 
Huxley's layer, 32 
Hybrid measles, 133 
Hydroa, 219 
Hydrosis, 95 
Hyperaesthesise, 581 
Hyperhidrosis, 95 
Hyperidrosis, 95 

etiology, 96 

pathology, 97 

prognosis, 98 

symptoms, 95 

treatment, 97 
Hypertrichosis, 398 

etiology, 400 

treatment, 401 
Hypertrophies of muscular tissue, 462 
Hypertrophy of the hair, 398 

vessels, 464 
Hypohidrosis, 101 



TCHTHYOL, 77, 85 
1 Ichthyosis, 390 



Ichthyosis congenita, 392 

diagnosis, 394 

etiology, :!'.»:i 

hystrix, 890 

nacrea, 391 

nigricans, 391 

pathology, 393 

prognosis, 395 

sebacea, 110 

serpentina, 391 

simplex, 390 

treatment, 394 
Idrosis, 95 
Impetigo, 340 

contagiosa, 342 
diagnosis, 344 
etiology, 343 
pathology, 343 
symptoms, 342 
treatment, 344 

diagnosis, 341 

etiology, 341 

figurata, 258 

herpetiformis, 344 

pathology, 341 

symptoms, 340 

treatment, 342 

Infection, cadaveric, pustules from, 

201 
Inflammations of the skin, 129 
Inflammatory fungoid neoplasm, 578 
Inherited syphilis, 521 
Insects, wouuds inflicted by, 202 
Internal treatment, 74 
Intertrigo, 156 

Iodide of potassium rashes, 182 
Iodine, 76 

Iodine eruption, 182 
Iodized phenol of Bellamy, 289 
Itch, 631 

lumbermen's, 589 

Malabar, 611 

Norwegian, 636 

prairie, 589 

swamp, 589 
Itching of the anus, 583 

of the genitals, 583 

of the nose, 583 

of the skin, 581 
Ixodes, 648 

Americanus, 648 

bovis, 648 

humanus, 648 

marginatus, 648 

ricinis, 648 

unipunetatus, 648 



TABORANDI, 77 
J eruption, 183 

Jequirity, 86 



INDEX. 



KAOLIN, 82, 123 
Kaposi's sulphur paste, 327 
Kelis, 447 
Keloid, 447 

diagnosis, 449 

etiology, 448 

pathology, 448 

prognosis, 449 

symptoms, 447 

treatment, 449 
Keratoses, 366 

diagnosis, 367 

etiology, 367 

pathology, 367 
Keratosis pilaris, 366 

senilis, 368 

treatment, 368 
Kerion Celsi, 617 
Klamann's dusting powder, 158 
Kriptoptes monunguiculosis, 645 



f ACQUER-WABE rash, 174 

Li Lanolin, 84 

La perleche, 631 

Large pustular scrofuloderm, 493 

La Rosa, 560 

Lead pastes, 82 

Leiomyoma, 462 

Lenses, 88 

Lenticular cancer, 573 

Lentigo, 360 

etiology, 360 

pathology, 361 

symptoms, 360 

treatment, 361 
Leontiasis, 549 
Lepra, 221, 549 

anaesthetica, 553 

Arabum, 549 

diagnosis, 558 

etiology, 554 

maculosa, 552 

pathology, 556 

prognosis, 559 

symptoms, 549 

treatment, 558 

tuberosa, 549 
, Leprosy, 549 

Lombardy, 560 
Leptus, 645 

autumnalis, 645 
Lesions, consecutive, 53 

elementary, 49 

names descriptive of, 57 
Leucoderma, 422 

symptoms, 422 
Leucoplakia buccalis, 224, 247 
Lichen annulatus serpiginosus, 240 
(note) 

eczematodes, 254 



Lichen pilaris, 366 
planus, 246 

diagnosis, 249 
etiology, 248 
pathology, 248 
prognosis, 249 
symptoms, 246 
treatment, 249 
ruber, 250 

diagnosis, 251 
etiology, 251 
moniliformis, 247 
pathology,. 251 
prognosis, 252 
symptoms, 250 
treatment, 251 
scrofulosorum, 491 
tropicus, 314 
urticatus, 164 
Liodermia cum melanosi et telangiec- 
tasia, 466 
Liquor picis alkalinus, 286 
Lithsemia, 65 
Lithsemic diathesis, 65 
Livedo, 155 
Liver-spots, 361, 628 
Lombardy leprosy, 560. 
Lotions, 80 
Louse, crab, 655 
of body, 652 
of head, 649 
of pubes, 655 
Lousiness, 649 
Lumbermen's itch, 589 
Lunula, 47 

Lupus disseminatus, 480 
erythematodes, 473 
erythematosus, 473 
diagnosis, 476 
etiology, 475 
pathology, 476 
prognosis, 479 
symptoms, 473 
treatment, 477 
exedens, 479 
exfoliativus, 480 
hypertrophicus, 480 
of ears, 486 
of extremities, 487 
of face, 485 
of genital region, 486 
of mucous membrane, 487 
of trunk, 486 
sclerosus, 480 
sebaceus, 473 
serpiginosus, 480 
superficialis, 473 
tuberculosus, 480 
vegetans, 480 
verrucosus, 480 
vorax, 479 



670 



INDEX. 



Lupus vulgaris, 479 

diagnosis, 484 
etiology, 481 
pathology, 482 

symptoms, 479 
treatment, 487 
Lycopodium, S3 
Lymphaden ectasia, 471 
Lymphad&nie cutanee, 578 
Lymphaugiectasic fibromyoma, -t< »- J 
Lymphangioma, 470 

tuberosum multiplex, 470 
Lymphatic currents, 29 

sarcoma, -377 

vessels, 28 
Lymph scrotum, 417 
Lyomyoma, 462 



MACUL.E, 49 
Madura foot, 495 

Malabar itch, 611 

Malignant anginose scarlatina, 136 

Malignant pustule, 205 

Mai pb- for ant clu pied, 375 

Malum perfbrans pedis, 375 

Mange, lower animals, 615 

Marsden's paste, 570 

Martin bandage, 310 

Matrix of nail, 45 

Measles, 130 

black, 143 
Medicated soaps, 81 
Medicinal rashes, 178 
Medulla of hair, 38 
Medullated nerves, 30 
Melanoderma, 361 

cachecticorum, 362 
Melano-sarcoma, 577 
Melanosis lenticularis progressiva, 466 
Melanotic carcinoma, 574 
Mellitagra, 258 
Mentagra, 334 
Mercury, 7o, 87 

eruption, 183 
Microsporon furfur, 626 

minutissimum, 629 
Midges, 659 
Miliary fever, 100 
Milium, 124 

diagnosis, 126 

etiology, 125 

needle, 89 

pathology, 12") 

symptoms, 124 

treatment, 126 
Milk-crust, 109 
Mineral springs, 78 
Molluscous corpuscles, :!71 
Molluscum contagiosum, 369 

epitheliale, 369, 370 



Molluscum epitheliale, diagnosis, :;72 
etiology, .'!7o 
pathology, ".71 
prognosis, :;74 
symptoms, 369 
treatment. .'174 
verrucosum, 373 
Morbilli, 130 

diagnosis, 132 
Morbus coeruleus, 155 

maculosus Werlhofii. :;•"■<; 
Morphcea, 409 

diagnosis, 411 
etiology, 411 
pathology, 411 
prognosis, 412 
symptoms, 409 
treatment, 411 
Mosquitoes, 659 
Mother's marks, 466 
Mucous layer, 25 

patch, 511 
Mulberry marks, 466 
.Mulls, 83 
Multiple cachectic gangrene, 188 

cutaneous tumor, accompanied by 
pruritus, 385 
Murrain, 205 
Muscles, 32 
Muslins, salve, 83 
Mycetoma, 495 
Mycosis framboesioides, 41 9 
fungoides, 578 
etiology, 579 
prognosis, 581 
pathology, 580 
treatment, 580 
microsporina, 625 
Myoma, 462 

telangiectodes, 463 
Myringomycosis, (129 
Myxoedema, 595 
etiology, 596 
pathology, "''.Hi 
symptoms, 595 
Mvxo-sarcoma, 577 



N.EVOID elephantiasis. 417 
Nsevus aranaeus, 465 
Nsevus flammeus, 465 
lipomatodes, 387 
mollusciformis, 387 
pigmentosus, 387 

pathology, 388 
pilosus, 38"! 
spilus, 387 
unius lateris, 388 
vasculosus, 464 
verrucosus, 387 
vinosus, 466 



671 



Nail-fold, 46 
Nails, 45 
Naphthol, 86 
Needle-holders, 88 
Needles, irido-platinurn, 89 

milium, 89 
Nerves, 29 
Nervous papillae, 24 
Nettle-rash, 163 
Neuroma, 456 
Neuropathic plica, 400 
Neuroses, 581 

trophic, 592 

vasomotor, 592 
Neurotic excoriations, 593 
New growths, 447 

of connective tissue, 447 
Nodose swellings of shafts of hairs, 442 
Non-medullated nerves, 29 
Non-striated muscular fibres, 32 
Norwegian itch, 636 



OBJECTIVE symptoms, 48 
Odors of the skin, 44 
GEstrus bovis, 647 
Ohio scratches, 589 
Oils and fats, 81 
Oleates, 84 
Oleum rusci, 85 
Onychauxis, 395 

pathology, 397 

prognosis, 397 

symptoms, 395 

treatment, 397 
Onychia, syphilitic, 396 
Onychomycosis, 396, 606 
Opium eruption, 184 
Oriental lotion, 328 
Osmidrosis, 102 

" Overflow " of bladder producing inter- 
trigo, 157 



PACHYDERMIA, 412 
X lymphangiectatica, 471 
Pacinian corpuscles, 30 
Paget's disease of nipple, 307/566 
Palmar and plantar syphilides, 512 
Panniculus adiposus, 20 
Papilla?, 23 

Papillary epithelioma, 563 
Papilloma, 385 

Papular scrofuloderm, the, 491 
Papules, 50 
Parangi, 421 
Parasitic affections, 596 
Paronychia, 395 
Pars papillaris, 22 
reticularis, 22 
Pastav's salve, 642 



- ? X 
Pediculi from lower animals, 657 

Pediculosis, 649 

capillitii, 649 

corporis, 652 

pubis, 655 

symptoms, 649 
Peliosis rheumatica, 355 
Pellagra, 560 
Pemphigus, 219, 348 

acutus contagiosus adultorum, 342 

aigu prurigineux, 219 

benignus, 348 

circinatus, 219, 348 

compose, 219 

diagnosis, 351 

disseminatus, 348 

diutinus, 348 

etiology, 350 

hsemorrhagicus, 348 

hystericus, 212 

-like dermatitis, 219 

malignus, 349 

pathology, 350 

prognosis, 353 

prurigineux, 219 

pruriginosus, 349 

solitarius, 348 

symptoms, 348 

treatment, 352 

vulgaris, 348 
Perforating ulcer of foot, 375 
diagnosis, 377 
pathology, 377 
prognosis, 377 
symptoms, 376 
treatment, 377 
Permanent removal of superfluous hair 

by electrolysis, 401 
Pernio, 177 
Petechia?, 50, 354 
Phenol-camphor, 87 
Phenol, iodized (of Bellamy), 289 
Phlegmona diffusa, 204 
Phosphorus, 77 

eruption, 184 
Phtheiriasis, 649 
Phymata, 52 

Physiology of the skin, 17 
Pian, 419 
Piebald skin, 422 
Piedra, 443 
Pied skin, 422 
Pied tabetique, 594 
Piffard's acne lotion, 123 
Pigment, 32 
Pigmentary moles, 387 

syphilide, 506 
Pigment disorders, 360, 422 
Pigmented carcinoma, 574 
Pills, Asiatic, 75 



672 



Pilocarpine, 77 
eruption, 183 

Pitting in variola, prevention of, 148 
Pityriasis capitis, 43.'! 

maculate et circinata, 239 
diagnosis, 240 

etiology, 239 
pathology, 239 
symptoms, 239 

pilaris, 366 

rubra, 243 

diagnosis, 245 
pathology, 244 
symptoms, 243 
treatment, 246 
tabescentium, 110 
versicolor, &2~> 
Pix liquida, 85 

Plantar and palmar syphilodermata, 512 
Plaque muqueuse, 511 
Plaster-mulls, 84 
Plasters, 83 
Pleximeter, 90 
Plica neuropathica, 400 
Podelcoma, 495 
Podophyllin eruption, 184 
Poison ivy, 172 
Poliosis, 427 

circumscripta acquisita, 424 
Polonica, 400 
Polyidrosis, 95 
Polypapilloma tropica, 419 
Pomphi, 50 

"Porcupine" skin, 121, 391 
Pores, sweat, 42 
Porrigo larvalis, 258 
Port-wine mark, 465 
Post mortem tubercle, 386 
Potash soaps, 80 
Powders, 83 
Prairie itch, 589 

Precautions in treating favus and ring- 
worm, 624 
Prickle-cells, 25 
Prickle layer, 25 
Prickly heat, 61, 99, 314 
Prognosis, general, 71 
Prurigo, 316 

agria, 316 

dermanyssique, 657 

diagnosis, 318 

etiology, 316 

ferox, 316 

hyemalis, 588 

mitis, 316 

pathology, 317 

symptoms, 316 

treatment, 318 

winter, 588 
Pruritus, 581 

ani, 583 



Pruritus, diagnosis, 584 

etiology, 583 

genitalium, 583 

hiemalis, 588 

narium, 583 

pathology, 584 

prognosis, 588 

senilis, 583 

symptoms, 581 

treatment, 585 
Psora, 221 
Psoriasis, 221 

buccalis, 247 

circinata, 221 

diagnosis, 227 

diffuse, 221 

etiology, 224 

figurata, 221 

guttata, 221 

gyrata, 221 

lingual, 224 

nummularis, 221 

orbicularis, 221 

pathology, 225 

prognosis, 238 

punctata, 221 

symptoms, 221 

treatment, 230 
Ptomaines, 202 
Pulex irritans, 659 

penetrans, 643 
Punch, cutaneous, 90 
Purpura, 354 

hsemorrhagica, 356 

pathology, 358 

pulicosa, 357 

rheum atica, 355 

scorbutica, 357 

simplex, 354 

treatment, 359 

urticans, 355 

urticata, 164 
Pustulse, 52 
Pustula maligna, 205 
etiology, 206 
pathology, 206 
Pustules, 52 

from cadaveric infection, 201 



QUININE, 76 
eruption, 184 



RASHES, medicinal, 178 
Easpberry sore, 1 52 
Ray-fungus, 561 
Raynaud's disease, 188 
Repercussion of exanthemata, 133 
Reptiles and insects, wounds inflicted 
by, 202 



INDEX. 



673 



Resorcin, 86 
Eete Malpighii, 25 

mucosum, 25 
Rhagades, 55 

Rhinocoprion penetrans, 643 
Rhinophyma, 330 
"Khinosceros" skin, 391 
Rhinoscleroma, 471 

diagnosis, 473 

etiology, 472 

pathology, 472 

prognosis, 473 

symptoms, 471 

treatment, 473 
Rhus toxicodendron, 172 
Ringworm, Burmese, 611 

of beard, 618 

of body, 604 

of scalp, 611 
Hisipola Lombarda, 560 
Rodent ulcer, 562 
Root of the hair, 37 
Root-sheaths of the hair, 35 
Rosacea, 329, 417, 465 

diagnosis, 419 

etiology, 418 

pathology, 418 

prognosis, 419 

symptoms, 417 

treatment, 419 
Rosacea erythematosa, 417 

hypertrophica, 418 
Roseola, 154 

vaccinia, 152 

variolous, 140 
Rotheln, 133 
Rubella, 133 
Rubeola, 130 
Rumex salve, 327 
Rupia, 516 



SALICYLIC acid eruption, 185 
U "Salt rheum," 529 
Salve muslins, 83 
Sand flea, 643 
Santonine eruption, 185 
Sarcoma, 575 

alveolar, 577 

etiology, 576 

melanotic, 577 

pathology, 576 

symptoms, 575 

treatment, 577 
Sarcopsylla Westwood, 643 
Sarcoptes, 637 
Sarg's fluid soap, 81 
Sartian disease, the, 497 
Scabies, 631 

diagnosis, 638 

etiology, 637 



Scabies, Norwegian, 636 

pathology, 637 

prognosis, 642 

symptoms, 631 

treatment, 640 
Scales, 53 
Scarf-skin, 24 
Scarlatina, 134 
Scarlatiniibrm typhus, 137 
Scarlet fever, 134 

rash, 134 
Scars, 56 

vaccine, 150 
Schultze's modification of Pastav's 

formula, 642 
Scirrhous cancer, 573 
Sclerema, 405 
Sclereme en placards, 405 
Sclerema neonatorum, 404 

diagnosis, 405 

etiology, 404 

pathology, 404 

symptoms, 404 

treatment, 405 
Scleriasis, 405 
Sclerodactylia, 407 
Scleroderma, 405 

diagnosis, 408 

etiology, 407 

pathology, 408 

prognosis, 409 

symptoms, 406 

treatment, 409 
Scorbutus, 489 
Scrofula, 489 

Scrofulide tuber culeuse, 479 
Scrofuloderm, large pustular, 493 

papular, 491 

small pustular, 492 
Scrofuloderma, 489 

diagnosis, 493 

etiology, 493 

symptoms, 489 

treatment, 493 
" Scrofulous ringworm," 473 

ulcers, 529 
Scurvy, 357 

Scutulum of favus, 598' 
Sebaceous cyst, 124 

glands, 39 

diseases of, 107 

secretion, 40 
Seborrhcea, 107 

capillitii, 108 

congestiva, 113 

diagnosis, 112 

etiologv, 111 

faciei, 109 

generalis, 110 

genitalium, 110 

oleosa, 111 



43 



674 



INDEX. 



Seborrhoea, pathology, 112 

prognosis of, 118 

sicca, 108 

symptoms, 107 

treatment, 114 

fcrunci, 109 
Septum lucidum, 26 
Shaft of the hair, 37 
Shingles, 212 
Simulia, 659 
Strop de Gibert, 541 
Skin-grafting scissors, 89 
Skin worms, 119 
Smallpox, 139 

Small pustular scrofuloderm, 492 
Smoker's patches, 224 
Soaps, 80 

medicated, 81 
Soda soaps, 80 
Sodium benzoate eruption, 185 

biborate eruption, 185 
Soft chancre, 544 
Spender's formula, 85 
" Spider-cancer,'' 465 
Spiritus saponis alkalinus (Hebra), 80, 

234 
Splenic apoplexy, 206 

carbuncle, 206 

fever, 206 
Spoons, dermal, 90 
Spots, 49 

Springs, mineral, 78 
Spud, 89 
Squamse, 53 
Stains, 49 
Starch, 83 

Startin's acid mixture, 114, 324 
Steatoma, 126 

diagnosis, 127 

pathology, 127 

prognosis, 128 

symptoms, 126 

treatment, 127 
Steatorrhoea, 107 
Steatozoon folliculorum, 642 
Stigmata, bleeding, 593 
Stinking-sweat, 102 
" Strait jacket," in eczema, 295 
Stramonium eruption, 185 
Stratum corneum, 27 

granulosum, 26 

lucidum, 26 

mucosum, 25 
Strawberry appearance of the tongue, 

135 
Strawberry marks, 466 
Striated muscular fibres, 32 
Struma, 489 
Strychnia eruption, 185 
Subcutaneous tissue, 19 
Subjective symptoms, 48 



Sudamen, 99 

diagnosis, 100 

etiology, 100 

pathology, 100 

treatment, 100 

symptoms, 99 
Sudatoria, 95 

Sudden blanching of hairs, 427 
Sudoriparous glands, 40 
Suette miliaire, 100 
Sulphur, 86 

baths, 80 

hypochloride, 117 
Sun-burn, 362 
Superficial epithelioma, 562 
Surgical appliances, 88 
Swamp-itch, 589 
Sweat, bloody, 106 

glands, 40 

diseases of, 95 
Sweating, excessive, 99 
Sweat-pore, 42 

stinking, 102 
Swine-pox, 142 
Sycosis, 334 

diagnosis, 336 

etiology, 335 

pathology, 336 

prognosis, 338 

symptoms, 334 

treatment, 337 
Symmetrical dry gangrene, 188 
Symmetry in eruptions, 68 
Symptoms, objective, 48 

subjective, 48 
Synanthemata, 57 
Synovial lesions of the skin, 496 
Syphilis following vaccination, 151 
Syphilitic treatment, "tonic," 534 
Syphilitic roseola, 504 
Syphiloderma, 497 

bullosum, 517 

diagnosis, 528 

etiology, 525 

gummatosum, 519 

hereditarium, 521 

infantile, 521 

maculosum, 504 

papulosum, 507 

large acuminate, 509 
large fiat, 510 
small acuminate, 507 
small flat, 509 

pathology, 526 

prognosis, 543 

pustulosum, 514 

large acuminate, 515 
large flat, 516 
small acuminate, 514 
small flat, 515 

treatment, 530 



INDEX. 



675 



Syphiloderma tuberculosum, 517 

serpiginosum, 517 

vesiculosum, 513 
Syphilodermata, 500 

general characteristics, 500 



Tache c'er'ebrale, 187 

Tactile corpuscles, 31 

Tan, 154, 360 

Tanacetum eruption, 186 

Tansy rash, 186 

Tar, 77, 84 

Tar-acne, 235 

Tar eruption, 186 

Tattooing, 49, 363 

Telangiectasis, 465 

Terms describing lesions of the skin, 

Terra alba. 82 

"Tetter," 529 

Therapeutics, general, 73 

Tinea circinata, 604 

diagnosis, 608 

etiology, 606 

pathology, 607 

prognosis, 611 

symptoms, 604 

treatment, 609 
favosa, 597 

diagnosis, 601 

etiology, 599 

pathology, 599 

prognosis, 603 

symptoms, 597 

treatment, 601 
imbricata, 611 
kerion, 617 
sycosis, 618 

diagnosis, 621 

etiology, 620 

pathology, 620 

prognosis, 624 

symptoms, 618 . 

treatment, 622 
tonsurans, 611 

diagnosis, 615 

etiology, 613 

pathology, 613 

prognosis, 617 

symptoms, 611 

treatment, 615 
trichophytina, 603 

cruris, 605 

unguium, 606 
versicolor, 625 

diagnosis, 527 

etiology, 626 

pathology, 626 

prognosis, 629 

symptoms, 625 

treatment, 628 



57 



Tipulidte, 659 

Tokelau ringworm, 611 

" Tonic treatment of syphilis," 534 

Toxicants, 62 

Traumaticine, 84 

Traumatism, 62 

Treatment, external, 79 

internal, 74 
Trichophyton, 606 
Trichorexis nodosa, 441 
Trophic neuroses, 592 
Tubercles, 51 
Tubercula, 51 

Tubercular epithelioma, 563 
Tuberculosis of the skin, 494 
Tuberose carcinoma, 573 
Tumor cavernosus, 467 
Tumores, 52 
Tumors, 52 

Turpentine eruption, 186 
Tyloma, 374 
Tylosis, 374 



TTLCEBS, 56 

U Unguentum Rochardi, 328 

Uridrosis, 105 

Urticse, 50 

Urticaria, 163 

diagnosis, 167 

etiology, 165 

pathology, 166 

pigmentosa, 164 

prognosis, 171 

symptoms, 163 

treatment, 168 

tuberosa, 165 



yACCINATION, 149 
' chancre, 151 

syphilis, 151 
Vaccine rashes, 152 
Vaccinia, 149 
Vaccinola, 152 
Varicella, 146 

diagnosis, 147 
Variola, 139 

diagnosis, 145 

etiology, 144 

hsemorrhagic, 143 

prognosis, 146 

treatment, 147 
Varioliform acne, 370 
Varioloid, 142 
Variolous erythema, 140 

roseola, 140 
Varix lymphaticus, 417 
Vascular papillae, 24 
Vaseline, 81 
Vaso-motor neuroses, 592 



676 



INDEX. 



Vegetable parasites, 597 
Veins, 27 
Vergetures, 446 
Verruca, 381 

acquisita, 381 

acuminata, 381 

congenita, 381 

etiology, 382 

filiformis, 381 

glabra, 382 

necrogenica, 386 

pathology, 382 

plana, 382 

prognosis, 385 

senilis, 382 

treatment, 384 

vulgaris, 382 
Vesicles, 52 
Vesiculse, 52 
Vespidse, 659 
Vi bices, 50, 354 
Vitiligo, 424 

diagnosis, 426 

etiology, 426 

pathology, 426 

prognosis, 427 

symptoms, 424 

treatment, 426 
Vitiligoidea, 458 
Vleminckx's solution, 80 



WART-CURES, 384 
Warts, 381 

Water, 79 
Wen, 126 
Wheals, 50 



note, 328 



White's "strait-jackets" for eczenra- 

tous infants, 295 
Wilkinson's salve, 235 
Wilson's arsenical solution, 114 
Winter prurigo, 588 
Wool- fat, 84 

XANTHELASMA, 458 
Xanthoma multiplex, 469 

Xanthoma planum, 458 

diagnosis, 461 

etiology, 459 

pathology, 460 

prognosis, 461 

symptoms, 458 

treatment, 461 

tuberosum, 459 
Xeroderma, 388 

pigmentosum, 466 
Xerosis, 388 

symptoms, 389 

V A WS, 419 



ZONA, 212 
Zoster, 212 
Zoster abdominalis, 215 
brachialis, 214 
capillitii, 214 
collaris, 214 
facialis, 214 
femoralis, 215 
frontalis, 214 
nucha?, 214 
ophthalmicus, 214 
pectoralis, 215 



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logue. No risks, however, are assumed either on the money or on the books, and no pub- 
lications but our own are supplied, so that gentlemen will in most cases find it more con- 
venient to deal with the nearest bookseller. 

LEA BEOTHEES & CO. 

Nos. 706 and 708 Sansom St., Philadelphia, April, 1888. 



PROSPECTUS FDR 1BBB. 



The Monthly Publication of 
The American Journal of the SVJedica! Sciences. 

To be issued at the beginning of each month. Over 100 large octavo pages 
of reading matter in each number. 



Subscription Price Reduced to $4.00 per annum. 

WITH the present year The American Journal of the Medical Sciences 
enters upon the cultivation of the larger field of usefulness which has awaited 
its change from a quarterly to a monthly. This change is simply a further development 
of that spirit which has caused The Journal, during two generations, to be always 
the leader in medical thought, divining the needs of the profession, and shaping 
itself for their adequate supply. The period thus far spanned by the life of The 
Journal is, par excellence, the Augustan Age of medicine. Never before in history have 
the brains of individual men been so heavily taxed, or so fertile in physical benefit to the 
human race. If the present rate of progress is to be accelerated or even maintained, it 
can only be by means of increased rapidity in the interchange of thought, and by a still 
greater condensation in bringing to the reader the results of the daily accumulating 
contributions to our knowledge of disease and its prevention or its remedies. To accom- 
plish this end The Journal of the future here devotes itself. Its position for the last 
sixty-eight years as the authoritative organ of the most advanced minds of the profession 
offers the surest guarantee of its future usefulness under its enlarged opportunities. 

Those friends who have become attached to the present form of The Journal will 
be gratified to learn that no change in its shape and appearance has been deemed advisa- 



2 Lea Brothers & Co.'s Periodicals — Am. Journal, Medical News. 

THE AMERICAN JOURNAL of the MEDICAL SCIENCES. 

As a Monthly. (Continued from first page.) 

ble. Its total yearly size will be somewhat increased, while its individual parts will be 
smaller and more convenient for mental and physical grasp. A larger proportion of 
space will be devoted to Original Articles, which will be on an average shorter than at 
present, so that every reader may not fail to find in each number something of direct 
interest to himself. The Department of Progress will continue to furnish an able and 
systematized epitome of the world's medical advance under the headings of Anatomy ; 
Physiology ; Materia Medica, Therapeutics and Pharmacology ; Medicine ; Surgery ; 
Ophthalmology ; Otology ; Laryngology ; Dermatology ; Midwifery and Gynecology ; 
Medical Jurisprudence and Toxicology, and Public Health, in charge of specialists whose 
respective positions are a sufficient earnest that, while nothing of interest is omitted, 
equal care is exercised that no opinion is advanced that is not worthy of the complete 
confidence of all practitioners. 

To accommodate the increase in these two divisions The Journal will be somewhat 
enlarged, and the Department of Reviews will be condensed without sacrifice of the 
pithiness and candor which have marked its literary judgments in the past. 

SUBSCRIPTION R\TE REDUCED TO $4.00 PER ANNUM. 

Basing their estimates upon the largely increased practical value of a monthly as 
compared with a quarterly, the publishers have decided that tbeir subscribers shall have 
the advantage of the decrease in cost per copy effected by the increased number to be 
printed. It is safe to say that in no other publication of its kind can an investment be 
made with the certainty of so rich a return. When taken in connection with the weekly 
Medical News, the reader can rest assured that nothing of importance in the life of the 
great medical world will escape his attention. To lead every subscriber to prove this fact 
for himself, the Commutation rate has been greatly reduced, being fixed at the exceedingly 
low figure of Seven Dollars and Fifty Cents Per Annum in Advance. 



THE MEDICAL NEWS. 

WEEKLY. 

28 to 32 Quarto Pages of Reading Matter. $5.00 per annum. 

FOUNDED as a monthly in 1843, The Medical News assumed a weekly form in 
1882, thereby inaugurating a marked and permanent change in American medical 
journalism. It undertook to supply a medical magazine and newspaper in the largest 
and highest sense of both terms, and to this end its energies have been devoted with 
unflagging assiduity. Presenting a conveniently large amount of well-digested matter 
each week, it enables the general practitioner to keep advised of the thought, experience 
and discoveries of his colleagues in all parts of the world at a minimum expense of time 
and money. Posted by its crisp journalism, and completing his knowledge with the more 
elaborate pages of the Monthly American Journal, the reader may feel secure that 
nothing of importance can escape him. To aid in extending the advantages of this 
combination, the publishers have decided to reduce the Commutation Kate for the two 
periodicals to Seven Dollars and Fifty Cents Per Annum in Advance. 



TERMS OF SUBSCRIPTION AND COMMUTATION RATE. 

The Medical News (weekly) $5.00 per annum. ~\ Together to one address, 

The American Journal of the Medical Sciences > by mail, $7.50 per an- 

(montbly) $4.00 per annum. J num, in advance. 

*# * Specimen copies of either of these periodicals will be sent, free of cost, on application 
to the publishers. 

SPECIAL OFFERS. 

J.rfwmce-paying subscribers to either or both of the above-named periodicals may take 
advantage of any one of the following offers: 

(1). The Medical News Visiting List for 1888, post-paid on receipt of 75 cents 
per volume (regular price $1.25). (2). The Year-P>ook of Treatment for 1886 or 1887 
(see page 17) will be sent on receipt of 75 cents (regular price $1.25). (3). An advance 



Lea Brothers & Co.'s Publications — Period., Manuals. 3 

remittance of $8.50 will procure The News and The Journal for one year, together 
with The Medical News Visiting- List and The Year- Book of Treatment for 
1886 or 1887, as offered above. Thumb-letter Index for quick use, 25 cents additional. 



Subscribers can obtain, at the close of each volume, cloth covers for The Journal (one 
annually), and for The News (one annually), free by mail, by remitting Ten Cents for the 
Journal cover, and Fifteen Cents for the News cover. 

B&&* The safest mode of remittance is by bank check or postal money order, drawn to 
the order of the undersigned ; where these are not accessible, remittances for subscriptions 
may be sent at the risk of the publishers by forwarding in registered letters. Address, 
LEA BEOTHEES & CO., 706 and 708 Sansom Street, Philadelphia. 



THE MEDICAL NEWS VISITING LIST FOR 1888 

Has been revised and brought thoroughly up to date in every respect. It con- 
tains 48 pages of text, including calendar for two years; obstetric diagrams; scheme 
of dentition; tables of weights and measures and comparative scales; instructions for ex- 
amining the urine; list of disinfectants; table of eruptive fevers; lists of new remedies 
and remedies not generally used ; incompatibles, poisons and antidotes ; artificial respira- 
tion ; table of doses, prepared to accord with the last revision of the U. S. Pharmacopoeia ; 
an extended table of Diseases and their remedies, and directions for ligation of ar- 
teries. 176 pages of blanks for all records of practice and erasable tablet. Handsomely 
bound in limp Morocco, with pocket, pencil, rubber and catheter scale. 

The Medical News Visiting List for 1888 is issued in three styles : Weekly, (for 
30 patients); Monthly, and Perpetual. Each, in one volume, $1.25. Also, furnished with 
Eeady Eeference Thumb-letter Index for quick use, 25 cents additional. For special 
offers, including Visiting List, see above. 



THE MEDICAL NEWS PHYSICIANS 9 LEDGER. 

Containing 400 pages of fine linen " ledger " paper, ruled so that all the accounts of a 
large practice may be conveniently kept in it, either by single or double entry, for a long 
period. Strongly bound in leather, with cloth sides, and with a patent flexible back, 
which permits it to lie perfectly flat when opened at any place. Price, $5.00. Also, 
a small special lot of same Ledger, with 300 pages. Price, $4.00. 



HARTSHORNE, HENRY, 4. M., M. D. 9 LL. D., 

Lately Professor of Hygiene in the University of Pennsylvania. 
A Conspectus of the Medical Sciences ; Containing Handbooks on Anatomy, 
Physiology, Chemistry, Materia Medica, Practice of Medicine, Surgery and Obstetrics. 
Second edition, thoroughly revised and greatly improved. In one large royal 12mo. 
volume of 1028 pages, with 477 illustrations. Cloth, $4.25 ; leather, $5.00. 



The object of this manual is to afford a conven- 
ient work of reference to students during the brief 
moments at their command while in attendance 
upon medical lectures. It is a favorable sign that 
it has been found necessary, in a short space of 
time, to issue a new and carefully revised edition. 
The illustrations are very numerous and unusu- 
ally clear, and each part seems to have received 
its due share of attention. We can conceive such 
a work to be useful, not only to students, but to 
practitioners as well. It reflects credit upon the 



industry and energy of its able editor.— Boston 
'/ and Surgical Journal, Sept. 3, 1874. 
We can say with the strictest truth that it is the 
best work of the kind with which we are ac- 
quainted. It embodies in a condensed form all 
recent contributions to practical medicine, and is 
therefore useful to every busypractitionerthrough- 
out our country, besides being admirably adapted 
to the use of students of medicine. The book is 
faithfully and ably executed. — Charleston Medical 
Journal, April, 1875. 



NEILL 9 JOHN, M. D., and SMITH, E. G., M. !>., 

Late Surgeon to the Penna. Hospital. Prof, of the Institutes of Med. in the Univ. of Penna. 

An Analytical Compendium of the Various Branches of Medical 
Science, for the use and examination of Students. A new edition, revised and improved. 
In one large royal 12mo. volume of 974 pages, with 374 woodcuts. Cloth, $4 ; leather, $4.75. 



LUDLOW, J.L.,M.D., 

Consulting Physician to the Philadelphia Hospital, etc. 

A Manual of Examinations upon Anatomy, Physiology, Surgery, Practice of 
Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy and Therapeutics. To which 
is added a Medical Formulary. 3d edition, thoroughly revised, and greatly enlarged. In 
one 12mo. volume of 816 pages, with 370 illustrations. Cloth, $3.25 ; leather, $3.75. 

The arrangement of this volume in the form of question and answer renders it espe- 
cially suitable for the office examination of students, and for those preparing for graduation. 



4 Lea Brothers & Co.'s Publications — Dictionaries. 

DUNGLISON, ROBLEY, M. L>„ 

Late Profesxor of Institutes of Medicine in thr, Jefferson Medical College of Philadelphia. 

MEDICAL LEXICON ; A Dictionary of Medical Science : Containing 

a concise Explanation of the various Subjects and Terms of Anatomy, Physiology, Pathol- 
ogy, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Juris- 
prudence and Dentistry, Notices of Climate and of Mineral "Waters, Formulae for Officinal, 
Empirical and Dietetic Preparations, with the Accentuation and Etymology of the Terms, 
and the French and other Synonymes, so as to constitute a French as well as an English 
Medical Lexicon. Edited by 1'ichard J. Dunglison, M. D. In one very large and 
handsome royal octavo volume ol 1139 pages. Cloth, $6.50; leather,.raised bands, $7.50; 
very handsome half Russia, raised bands, $8. 

The object of the author, from the outset, has not been to make the work a mere lexi- 
con or dictionary of terms, but to afford under each word a condensed view of its various 
medical relations, and thus to render the work an epitome of the existing condition of 
medical science. Starting with this view, the immense demand which has existed for the 
work has enabled him, in repeated revisions, to augment its completeness and usefulness, 
until at length it has attained the position of a recognized and standard authority wherever 
the language is spoken. Special pains have been taken in the preparation of the present 
edition to maintain this enviable reputation. The additions to the vocabulary are more 
numerous than in any previous revision, and particular attention has been bestowed on the 
accentuation, which will be found marked on every word. The typographical arrangement 
has been greatly improved, rendering reference much more easy, and every care has been 
taken with the mechanical execution. The volume now contains the matter of at least 
four ordinary octavos. 



About tne first book purchased by the medical 
student is the Medical Dictionary. The lexicon 
explanatory of technical terms is simply a sine qua 
non. In a science so extensive and with such col- 
laterals as medicine, it is as much a necessity also 
to the practising physician. To meet the wants of 
students and most physicians the dictionary must 
be condensed while comprehensive, and practical 
while perspicacious. It was because Dunglison's 
met these indications that it became at once the 
dictionary of general use wherever medicine was 
studied in the English language. In no former 

revision have the alterations and additions been | carried through, it is only necessary to state that 
rreat. The chief terms have been set in black 



passed away, probably all of us feared lest the book 
should not maintain its place in the advancing 
science whose terms it defines. Fortunately, Dr. 
Richard J. Dunglison, having assisted his father in 
the revision of several editions of the work, and 
having been, therefore, trained in the methods 
and imbued with the spirit of the book, has been 
able to edit it as a work of the kind should be 
edited— to carry it on steadily, without jar or inter- 
ruption, along the grooves of thought it has trav- 
elled during its lifetime. To show the magnitude 
of the task which Dr. Dunglison has assumed and 



so gre 

letter, while the derivatives follow in small caps; 
an arrangement which greatly facilitates reference. 
— Cincinnati Lancet and Clinic, Jan. 10, 1874. 

A book of which every American ought to be 
proud. When the learned author of the work 



bje 

added in the present edition.— Philadelphia Medical 
Times, Jan. 3, 1874. 

It has the rare merit that it certainly has no rival 
in the English language for accuracy and extent of 
references. — London Medical Gazette. 



HOBLYN, RICHARD D., M. D. 

A Dictionary of the Terms Used in Medicine and the Collateral 
Sciences. Revised, with numerous additions, by Isaac Hays, M. D., late editor of 
The American Journal of the Medical Sciences. In one large royal 12mo. volume of 520 
double-columned pages. Cloth, $1.50 ; leather, $2.00. 

It is the best book of definitions we have, and ought always to be upon the student's table. — Southern 
Medical and Surgical Journal. 

STUDENTS' SERIES OF MANUALS. 

A Series of Fifteen Manuals, for the use of Students and Practitioners of Medicine 
and Surgery, written by eminent Teachers or Examiners, and issued in pocket-size 
12mo. volumes of 300-540 pages, richly illustrated and at a low price. The following vol- 
umes are now ready : Treves' Manual of Surgery, by various writers, in three volumes, 
each, $2; Bell's Comparative Physiology and Anatomy, $2; Gould's Surgical Diagno- 
sis, $2; Robertson's Physiological Physics, $2 ; Bruce' s Materia Medica and. Therapeu- 
tics (4th edition), $1.50; Power's Human Physiology (2d edition), $1.50 ; Clarke and 
Lockwood's Dissectors' Manual, $1.50; Ralfe's Clinical Chemistry, $1.50; Treves' 
Surgical Applied Anatomy, $2; Pepper's Surgical Pathology, $2; and Klein's Elements of 
Histology (3d edition), $1.50. The following are in press: Bellamy's Operative Surgery, 
Pepper's Forensic Medicine, and Curnow's Medical Applied Anatomy. For separate 
notices see index on last page. 

SERIES OF CLINICAL MANUALS. 

In arranging for this Series it has been the design of the publishers to provide the 
profession with a collection of authoritative monographs on important clinical subjects 
in a cheap and portable form. The volumes will contain about 550 pages and will be 
freely illustrated by chromo-lithographs and woodcuts. The following volumes are 
now ready: Carter & Frost's Ophthalmic Surgery, $2.25; Hutchinson on Syphilis, 
$2.25 ; Ball on the Rectum and. Anus, $2.25 ; Marsh on the Joints, $2 ; Owen on Surgical 
Diseases of Children, $2 ; Morris on Surgical Diseases of the Kidney, $2.25 ; Pick on 
Fractures and Dislocations, $2; Butlin on the Tongue, $3.50; Treves on Intestinal 
Obstruction, $2: and Savage on Insanity and Allied Neuroses, $2. The following are in 
active preparation: Broapbent on the Pulse, and Lucas on Diseases of the Urethra. 
For separate notices see index on last page. 



Lea Brothers & Co.'s Publications — Anatomy. 



GBAY, HF1TIIY, F. M. S., 

Lecturer on Anatomy at St. George's Hospital, London. 

Anatomy, Descriptive and Surgical. The Drawings by H. V. Carter, M. D., 
and Dr. Westmacott. The dissections jointly by the Author and Dr. Carter. With 
an Introduction on General Anatomy and Development by T. Holmes, M. A., Surgeon to 
St. George's Hospital. Edited by T. Pickering Pick, F. R. C. S., Surgeon to and Lecturer 
on Anatomy at St. George's Hospital, London, Examiner in Anatomy, Royal College of 
Surgeons of England. A new American from the eleventh enlarged and improved London 
edition, thoroughly revised and re-edited by William W. Keen, M. D., Professor of 
Anatomy in the Pennsylvania Academy of the Fine Arts, etc. To which is added the 
second American from the latest English edition of Landmarks, Medical and Surgi- 
cal, by Luther Holden, F. R. C. S. In one imperial octavo volume of 1098 
pages, with 685 large and elaborate engravings on wood. Price of edition in black : 
Cloth, $6 ; leather, $7 ; half Russia, $7.50. Price of edition in colors (see below) : 
Cloth, $7.25 ; leather, $8.25 ; half Russia, $8.75. 

This work covers a more extended range of subjects than is customary in the ordinary 
text-books, giving not only the details necessary for the student, but' also the application to 
those details to the practice of medicine and surgery. It thus forms both a guide for the 
learner and an admirable work of reference for the active practitioner. The engravings 
form a special feature in the work, many of them being the size of nature, nearly all 
original, and having the names of the various parts printed on the body of the cut, in 
place of figures of reference with descriptions at the foot. In this edition a new departure 
has been taken by the issue of the work with the arteries, veins and nerves distinguished 
by different colors. The engravings thus form a complete and splendid series, which will 
greatly assist the student in forming a clear idea of Anatomy, and will also serve to refresh 
the memory of those who may find in the exigencies of practice the necessity of recall- 
ing the details of the dissecting-room. Combining, as it does, a complete Atlas of 
Anatomy with a thorough treatise on systematic, descriptive and applied Anatomy, 
the work will be found of great service to all physicians who receive students in their 
offices, relieving both preceptor and pupil of much labor in laying the groundwork of a 
thorough medical education. 

For the convenience of those who prefer not to pay the slight increase in cost necessi- 
tated by the use of colors, the volume will be published also in black alone, and main- 
tained in this style at the price of former editions, notwithstanding the largely increased 
size of the work. 

Landmarks, Medical and Surgical, by the distinguished Anatomist, Mr. Luther Holden, 
has been appended to the present edition as it was to the previous one. This work gives 
in a clear, condensed and systematic way all the information by which the practitioner can 
determine from the external surface of the body the position of internal parts. Thus 
complete, the work, it is believed, will furnish all the assistance that can be rendered 
by type and illustration in anatomical study. 



The most popular work on anatomy ever written. 
It is sufficient to say of it that this edition, thanks 
to its American editor, surpasses all other edi- 
tions.— Jour, of the Amer. Me". Ass'n, Dec. 31, 1887. 

A work which for more than twenty years has 
had the lead of all other text-books on anatomy 
throughout the civilized world comes to hand in 
such beauty of execution and accuracy of text 
and illustration as more than to make good the 
large promise of the prospectus. It would be in- 
deed difficult to name a feature wherein the pres- 
ent American edition of Gray could be mended 
or bettered, and it needs no prophet to see that 



the royal work is destined for many years to come 
to hold the first place among anatomical text- 
books. The work is published with black and 
colored plates. It is a marvel of book-making. — 
American Practitioner and News, Jan. 21, 1888. 

Gray's Anatomy is the most magnificent work 
upon anatomy which has ever been published in 
the English or any other language.— Cincinnati 
Medical Neivs, Nov. 1887. 

As the book now goes to the purchaser he is re- 
ceiving the best work on anatomy that is published 
in any language.— Virginia Med. Monthly, Dec. 1887. 



Also for sale separate — 
HOLDFW, LTJTHER, F. It. C. S., 

Surgeon to St. Bartholomew's and the Foundling Hospitals, London. 

Landmarks, Medical and Surgical. Second American from the latest revised 
English edition, with additions by W. W. Keen, M. D., Professor of Artistic Anatomy in 
the Pennsylvania Academy of the Fine Arts, formerly Lecturer on Anatomy in the Phila- 
delphia School of Anatomy. In one handsome 12mo. volume of 148 pages. Cloth, $1.00. 

This little book is all that can be desired within 
its scope, and its contents will be found simply in- 
valuable to the young surgeon or physician, since 
they bring before him such data as he requires at 
every examination of a patient. It is written in 
language so clear and concise that one ought 
almost to learn it by heart. It teaches diagnosis by 
external examination, ocular and palpable, of the 
body, with such anatomical and physiological facts 
as directly bear on the subject It is eminently 
the student's and young practitioner's book.— Phy- 
sician and Surgeon, Nov. 1881. 

The study of these Landmarks by both physi- 



cians and surgeons is much to be encouraged. It 
inevitably leads to a progressive education of both 
the eye and the touch, by which the recognition of 
disease or the localization of injuries is vastly as- 
sisted. One thoroughly familiar with the facts her* 
taught is capable of a degree of accuracy and a 
confidence of certainty which is otherwise unat- 
tainable. We cordially recommend the Landmarks 
to the attention of every physician who has not 
yet provided himself with a copy of this useful, 
practical guide to the correct placing of all the 
anatomical parts and organs.— Canada Medical and 
Surgical Journal, Dec. 1881. 



6 Lea Brothers & Co.'s Publications — Anatomy. 

ALLEN, HARBISON, M. D., 

Professor oj Physiology in the University of Pennsylvania. 

A System of Human Anatomy, Including Its Medical and Surgical 
Relations. For the use of Practitioners and Students of Medicine. With an Intro- 
ductory Section on Histology. By E. O. Shakespeare, M. D., Ophthalmologist to 
the Philadelphia Hospital. Comprising 813 double-columned quarto pages, with 380 
illustrations on 109 full page lithographic plates, many of which are in colors, and 241 
engravings in the text. In six Sections, each in a portfolio. Section 1. Histology. 
Section II. Bones and Joints. Section III. Muscles and Fascle. Section IV. 
Arteries, Veins and Lymphatics. Section V. Nervous System. Section VI. 
Organs of Sense, of Digestion and Genito-Urinary Organs, Embryology, 
Development, Teratology, Superficial Anatomy, Post-Mortem Examinations, 
and General and Clinical Indexes. Price per Section, $3.50 ; also bound in one 
volume, cloth, $23.00 ; very handsome half Russia, raised bands and open back, $25.00. 
For sale by subscription only. Apply to the Publishers. 

It is to be considered a study of applied anatomy care, and are simply superb. There is as much 

In its widest sense— a systematic presentation of of practical application of anatomical points to 

such anatomical facts as can be applied to the the every-day wants of the medical clinician as 

practice of medicine as well as of surgeiy. Our to those of the operating surgeon. In fact, few 

•uthor is concise, accurate and practical in his general practitioners will read the work without a 

statements, and succeeds admirably in infusing feeling of surprised gratification that so many 

an interest into the study of what is generally con- Doints, concerning which they may never have 

sidered a dry subject. The department of Histol- thought before are so well presented for their con- 

ogy is treated in a masterly manner, and the sideration. It is a work which is destined to be 

ground is travelled over by one thoroughly famil- the best of its kind in any language. — Medical 

lar with it. The illustrations are made with great | Record, Nov. 25,1882. 



CLABKE,W.B.,F.B.C.S. & LOCKWOOD,C. B.,F.B.C.S. 

Demonstrators of Anatomy at St. Bartholomew's Hospital Medical School, London. 
The Dissector's Manual. In one pocket-size 12mo. volume of 396 pages, with 
49 illustrations. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 4. 

Messrs. Clarke and Lock wood have written a book i intimate association with students could have 
that can hardly be rivalled as a practical aid to the given. With such a guide as this, accompanied 
dissector. Their purpose, which is "how to de- by so attractive a commentary as Treves' Surgical 
scribe the best way to display the anatomical Applied Anatomy (same series), no student could 
structure," has been fully attained. They excel in fail to be deeply and absorbingly interested in the 
a lucidity of demonstration and graphic terseness study of anatomy. — iVeio Orleans Medical and Sur- 
of expression, which only a long training and gical Journal, April, 1884. 



TBEVES, FBEDEBICK, F. B. C. S., 

Senior Demonstrator of Anatomy and Assistant Surgeon at the London Hospital, 
Surgical Applied Anatomy. In one pocket-size 12mo. volume of 540 pages, 
with 61 illustrations. Limp cloth, red edges, $2.00. See Students' Series of Manuals, 
page 4. 

He has produced a work which will command a ' quickened by daily use as a teacher and practi- 
larger circle of readers than the class for which it tioner, has enabled our author to. prepare a work 
was written. This union of a thorough, practical which it would be a most difficult task to excel. — 
acquaintance with these fundamental branches, , The American Practitioner, Feb. 1884. 



CUBNOW, JOHN, M. D., F. B. C. P., 

Professor of Anatomy at King's College, Physician at King's College Hospital. 
Medical Applied Anatomy. In one pocket-size 12mo. volume. Shortly. See 
Students' Series of Manuals, page 4. 

BELLAMY, EJDWABH, F. B. C. S., 

Senior Assistant-Surgeon to the Charing-Cross Hospital, London. 

The Student's Guide to Surgical Anatomy: Being a Description of the 
most Important Surgical Eegions of the Human Body, and intended as an Introduction to 
operative Surgery. In one 12mo. volume of 300 pages, with 50 illustrations. Cloth, $2.25. 

WILSON, EBASMUS, F. B. S. 

A System of Human Anatomy, General and Special. Edited by W. H. 
Gobrecht, M. D., Professor of General and Surgical Anatomy in the Medical College of 
Ohio. In one large and handsome octavo volume of 616 pages, with 397 illustrations. 
Cloth, $4.00; leather, $5.00. 

CLELAND, JOHN, 31. 2>., F. B. S„ 

Professor of Anatomy and Physiology in Queen's College, Gahcai/. 

A Directory for the Dissection of the Human Body. In one 12mo. 
volume of 178 pages. Cloth, $1.25. 

HARTSHORNE'S HANDBOOK OF ANATOMY HORNER'S SPECIAL ANATOMY AND HISTOL- 

AND PHYSIOLOGY. Second edition, revised. J OGY. Eighth edition, extensively revised and 

In one royal 12mo. volume of 310 pages, with 220 modified. In two octavo volumes of 1007 rages, 

woodcuts. Cloth, $1.75. I with 320 woodcuts. Cloth, 86.00. 



Lea Brothers & Co.'s Publications — Physics, Physiol., Anat. 7 
DRAPER, JOHN C., M. J)., LL. D., 

Professor of Chemistry in the University of the City of New York. 

Medical Physics. A Text-book for Students and Practitioners of Medicine. In 
one octavo volume of 734 pages, with 376 woodcuts, mostly original. Cloth, $4. 
FROM THE PREFACE. 

The fact that a knowledge of Physics is indispensable to a thorough understanding of 
Medicine has not been as fully realized in this country as in Europe, where the admirable 
works of Desplats and Gariel, of Eobertson and of numerous German writers constitute a 
branch of educational literature to which we can show no parallel. A full appreciation 
of this the author trusts will be sufficient justification for placing in book form the sub- 
stance of his lectures on this department of science, delivered during many years at the 
University of the City of New York. 

Broadly speaking, this work aims to impart a knowledge of the relations existing 
between Physics and Medicine in their latest state of development, and to embody in the 
pursuit of this object whatever experience the author has gained during a long period of 
teaching this special branch of applied science. 

explained, acoustics, optics, heat, electricity and 



This elegant and useful work bears ample testi- 
mony to the learning and good judgment of the 
author. He has fitted his work admirably to the 
exigencies of the situation by presenting the 
reader with brief, clear and simple statements of 
such propositions as he is by necessity required to 
master. The subject matter is well arranged, 
liberally illustrated and carefully indexed. That 
it will take rank at once among the text-books is 
certain, and it is to be hoped that it will find a 
place upon the shelf of the practical physician, 
where, as a book of reference, it will be found 
useful and agreeable.— Louisville Medical News, 
September 26, 1885. 

Certainly we have no text-book as full as the ex- 
cellent one he has prepared. It begins with a 
statement of the properties of matter and energy. 
After these the special departments of physics are 



magnetism, closing with a section on electro- 
biology. The applications of all these to physiology 
and medicine are kept constantly in view. The 
text is amply illustrated and the many difficult 
points of the subject are brought forward with re- 
markable clearness and ability. — Medical and Surg- 
ical Reporter, July 18, 1885. 

That this work will greatly facilitate the study 
of medical physics is apparent upon even a mere 
cursory examination. It is marked by that scien- 
tific accuracy which always characterizes Di. 
Draper's writings. Its peculiar value lies in the 
fact that it is written from the standpoint of the 
medical man. Hence much is omitted that ap- 
pears in a mere treatise on physical science, while 
much is inserted of peculiar value to the physi- 
cian.— Medical Record, August 22, 1885. 



ROBERTSON, J. McGREGOR, M. A., M. B., 

Muirhead Demonstrator of Physiology, University of Glasgow. 
Physiological Physics. In one 12mo. volume of 537 pages, with 219 illustra- 
tions. Limp cloth, $2.00. See Students' Series of Manuals, page 4. 

The title of this work sufficiently explains the ments. It will be found of great value to the 
nature of its contents. It is designed as a man- practitioner. It is a carefully prepared book of 
ual for the student of medicine, an auxiliary to reference, concise and accurate, and as such we 
his text-book in physiology, and it would be particu- heartily recommend it.— Journal of the American 
larly useful as a guide to his laboratory experi- Medical Association, Dec. 6, 1884. 

DALTON, JOHN C., M. H., 

Professor Emeritus of Physiology in the College of Physicians and Surgeons, New York. 
Doctrines of the Circulation of the Blood. A History of Physiological 
Opinion and Discovery in regard to the Circulation of the Blood. In one handsome 
12mo. volume of 293 pages. Cloth, $2. 

Dr. Dalton'swork is the fruit of the deep research revolutionized the theories of teachers, than the 
of a cultured mind, and to the busy practitioner it discovery of the circulation of the blood. This 
cannot fail to be a source of instruction. It will explains the extraordinary interest it has to all 
inspire him with a feeling of gratitute and admir- medical historians. The volume before us is one 
ation for those plodding workers of olden times, of three or four which have been written within a 
who laid the foundation of the magnificent temple few years by American physicians. It is in several 
of medical science as it now stands. — New Orleans respects the most complete. The volume, though 
Medical and. Surgical Journal, Aug. 1885. small in size, is one of the most creditable con- 

In the progress of physiological study no fact tributions from an American pen to medical history 
was of greater moment, none more completely | that has appeared. — Med. & Surg. Rep., Dec. 6, 1884. 

BELL, F. JEFFREY, M. A., 

Professor of Comparative Anatomy at .King's College, London. 

Comparative Physiology and Anatomy. In one 12mo. volume of 561 pages, 
with 229 illustrations. Limp cloth, $2.00. See Students' Series of Manuals, page 4. 

The manual is preeminently a student's book — 1 it the best work in existence in the English 
clear and simple in language and arrangement. I language to place in the hands of the medical 
It is well and abundantly illustrated, and is read- student. — Bristol Medico- Chirurgical Journal, Mar., 
able and interesting. On the whole we consider | 1886. 

ELLIS, GEORGE VINER, 

Emeritus Professor of Anatomy in University College, London. 

Demonstrations of Anatomy. Being a Guide to the Knowledge of the 
Human Body by Dissection. From the eighth and revised London edition. In one very- 
handsome octavo volume of 716 pages, with 249 illustrations. Cloth, $4.25 ; leather, $5.25. 

ROBERTS, JOHN B., A. M., M. !>., 

Prof, of Applied Anat. and Oper. Surg, in Phila. Polyclinic and Coll. for Graduates in Medicine. 
The Compend of Anatomy. For use in the dissecting-room and in preparing 
for examinations. In one 16mo. volume of 196 pages. Limp cloth, 75 cents. 



8 Lea Brothers & Cp.'s Publications — Physiology, Chemistry. 



CHAPMAN, HENRY C, M. D., 

Professor of Institutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of 
Philadelphia. 

A Treatise on Human Physiology. In one handsome octavo volume of 
925 pages, with 605 fine engravings. Cloth, $5.50; leather, $6.50. Just ready. 
It represents very fully the existing state of I farther, and the latter will find entertainment and 



physiology. The present work has a special value 
to the student and practitioner as devoted more 
to the practical application of well-known truths 
which the advance of science has given to the 
profession in this department, which may be con- 
sidered the foundation of rational medicine. — Buf- 
falo Medical and Surgical Journal, Dec. 1887. 

Matters which have a practical bearing on the 
practice of medicine are lucidly expressed ; tech- 
nical matters are given in minute detail; elabo- 
rate directions are stated for the guidance of stu- 
dents in the laboratory. In every respect the 
work fulfils its promise, whether as a complete 
treatise for the student or for the physician ; for 



instruction in an admirable book of reference. — 
North Carolina Medical Journal, Nov. 1887. 

The work certainly commends itself to both 
student and practitioner. What is most demanded 
by the progressive physician of to-day is an adap- 
tation of physiology to practical therapeutics, and 
this work is a decided improvement in this respect 
over other works in the market. It will certainly 
take place among the most valuable text-books. — 
Medical Age, Nov. 25, 1887. 

It is the production of an author delighted with 
his work, and able to inspire students with an en 
thusiasm akin to his own.— American Practitioner 



the former it is so complete that he need look no | and News, Nov. 12, 1887. 



DALTON, JOHN C, M. H., 

Professor of Physiology in the College of Physicians and Surgeons, New York, etc. 
A Treatise on Human Physiology. Designed for the use of Students and 
Practitioners of Medicine. Seventh edition, thoroughly revised and rewritten. In one 
very handsome octavo volume of 722 pages, with 252 beautiful engravings on wood. Cloth, 
$5.00 ; leather, $6.00 ; very handsome half Russia, raised bands, $6.50. 

This edition of Dr. Dalton's well-known work I sands who have studied it in its various editions 
bears evidence of having been thoroughly and j have never been in any doubt as to its sterling 
careiuiiy revised. From the first appearance of \ worth. — N. 1*. Medical Journal, Oct. 1882. 
the book it has been a favorite, owing as well to ' Professor Dalton's well-known and deservedly- 
the author's renown as an oral teacher as to the j appreciated work has long passed the stage at 
charm of simplicity with which, as a writer, he j which it could be reviewed in the ordinary sense, 
always succeeds in investing even intricate sub- j The work is eminently one for the medical prac- 
jects' It must be gratifying to him to observe the titioner, since it treats'mostfully of those branches 
frequency with which his work.written for students j of physiology which have a direct bearing on the 
and practitioners, is quoted by other writers on diagnosis and treatment of disease. The work is 
physiology. This fact attests its value, and, in I one~whieh we can highly recommend to all our 
great measure, its originality. It now needs no l readers.— Dublin Journal of M edical Science, Feb.'83. 
such seal of approbation, however, for ihe thou- I 

FOSTER, MICHAEE, M. H., F. R. S., 

Prelector in Physiology and Felloiv of Trinity College, Cambridge, England. 
Text-Book of Physiology. Third American from the fourth English edition, 
with notes and additions by E. T. Reichert, M. D., Professor of Physiology in the Uni- 
versitv of Pennsylvania. In one handsome royal 12mo. volume of 908 pages, with 271 
illustrations. Cloth, $3.25 ; leather, $3.75. 

Dr. Foster's work upon physiology is so well- I to know and what may be passed over by them as 
known as a text-book in this country, that it needs not important. From the beginning to the end, 
but little to be said in regard to it. There is physiology is taught in a systematic manner. To 
scarcely a medical college in the United States this third" American edition numerous additions, 
where it is not in the hands of the students. The corrections and alterations have been made, so 
author, more than any other writer with whom that in its present form the usefulness of the book 
we are acquainted, seems to understand what will be found to be much increased. — Cincinnati 
portions of the science are essential for students j Medical News, July 1885. 

POWER, HENRY, M. B., F. R. C. S., 

Examiner in Physiology, Royal College of Surgeons of England. 
Human Physiology. Second edition. In one handsome pocket-size 12mo. vol- 
ume of 396 pp., with 47 illustrations. Cloth, $1.50. See Students' Series of Manuals, p. 4. 

SIMON, W., Ph. D., M. Z>., 

Professor of Chemistry and Toxicology in the College of Physicians and Surgeons, Baltimore, and 
Professor of Chemistry in the Maryland College of Pharmacy. 

Manual of Chemistry. A Guide to Lectures and Laboratory work for Beginners 
in Chemistry. A Text-book, specially adapted for Students of Pharmacy and Medicine. 
In one 8vo. vol. of 410 pp., with 16 woodcuts and 7 plates, mostly of actual deposits, 
with colors illustrating 56 of the most important chemical reactions. Cloth, $3.00; also 
without plates, cloth, $2.50. 



This book supplies a want long felt by students j 
of medicine and pnarmacy. and is a concise but 
thorough treatise on the subject. The long expe- 
rience of the author as a teacher in schools of 
medicine ana pharmacy Is conspicuous in the 
perfect adaptation of the work to the special needs 
of the student of these branches. The colored 



plates, beautifully executed, illustrating precipi- 
tates of various reactions, form a novel and valu- 
able feature of the book, and cannot fail to be ap- 
preciated bv both student and teacher as a help 
over the hard places of the science.— Maryland 
Medical Journal, Nov. 22, 1884. 



Wohler's Outlines of Organic Chemistry. Edited by Fittig. Translated 
by Ira Remsen, M. D., Ph. D. In one 12mo. volume of 550 pages. Cloth, $3. 

LEHMANN'S MANUAL OF CHEMICAL PHYS- I CARPENTER'S PRIZE ESSAY ON THE USE AND 
IOLOGY. In one octavo volume of 327 pages, | Abuse or Alcoholic Liquors in Health and Dis- 
with 41 illustrations. Cloth,82.25. | ease. With explanationsof scientific words. Small 

CARPENTER'S HUMAN PHYSIOLOGY. Edited 12mo - " 8 P fl K es - c,otn - 6n cents - 
by Henry Power. In one octavo volume. I GALLOWAY'S QUALITATIVE ANALYSIS. 



Lea Brothers & Co.'s Publications — Chemistry. 



FRANKLANB, E. f D. C. L., F. R.S., &JAPF, F. R., F. I. C., 



Profe 



■ of Chemistry in the Normal School 
of Science, London. 



Assist. Prof, of Chemistry in the Normal 
School of Science, London. 



Inorganic Chemistry. In one handsome octavo volume of 677 pages with 51 
woodcuts and 2 plates. Cloth, $3.75 ; leather, $4.75. 

This work should supersede other works of its 
class in the medical colleges. It is certainly better 
adapted than any work upon chemistry, with which 
we are acquainted, to impart that clear and full 
knowledge of the science which students of med- 
icine should have. Physicians who feel that their 
chemical knowledge is behind the times, would 
do well to devote some of their leisure time to the 
study of this work. The descriptions and demon- 
strations are made so plain that there is no diffi- 
culty in understanding them. — Cincinnati Medical 
News, January, 1886. 



This excellent treatise will not fail to take its 
place as one of the very best on the subject of 
which it treats. We have been much pleased 
with the comprehensive and lucid manner in 
which the difficulties of chemical notation and 
nomenclature have been cleared up by the writers. 
It shows on every page that the problem of 
rendering the obscurities of this science easy 
of comprehension has long and successfully 
engaged the attention of the authors.— Medical 
and Surgical Reporter, October 31, 1885. 



FOWNES, GEORGE, Ph. J). 

A Manual of Elementary Chemistry; Theoretical and Practical. Em- 
bodying Watts' Physical Inorganic Chemistry. New American edition. In one large 
royal 12mo. volume of 1061 pages, with 168 illustrations on wood and a colored plate. 
Cloth, $2.75 ; leather, $3.25. 

chemistry extant.— Cincinnati Medical News, Oc- 
tober, 1885. 

Of all the works on chemistry intended for the 
use of medical students, Fownes' Chemistry is 

Eerhaps the most widely used. Its popularity is 
ased upon its excellence. This last edition con- 
tains all of the material found in the previous, 
and it is also enriched by the addition of Watts' 
Physical and Inorganic Chemistry. All of the mat- 
ter is brought to the present standpoint of chemi- 
cal knowledge. We may safely predict for this 
work a continuance of the fame and favor it enjoys 
among medical students. — New Orleans Medical 
and Surgical Journal, March, 1886. 



Chemistry has been a standard text- 
book upon chemistry for many years. Its merits 
are very fully known by chemists and physicians 
everywhere in this country and in England. As 
the science has advanced by the making of new 
discoveries, the work has been revised so as to 
keep it abreast of the times. It has steadily 
maintained its position as a text book with medi- 
cal students. In this work are treated fully: Heat, 
Light and Electricity, including Magnetism. The 
influence exerted by these forces in chemical 
action upon health and disease, etc., is of the most 
important kind, and should be familiar to every 
medical practitioner. We can commend the 
work as one of the very best text-books upon 



ATTFIELB, JOtfJV, Eh. 1>., 

Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, etc. 

Chemistry, General, Medical and Pharmaceutical; Including the Chem- 
istry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, 
and their Application to Medicine and Pharmacy. A new American, from the tenth 
English edition, specially revised by the Author for America. In one handsome royal 
12mo. volume of 728 pages, with 87 illustrations. Cloth, $2.50 ; leather, $3.00. 

in sixteen years must have good qualities. It 
seem9 desirable to point out that feature of the 
book which, in all probability, has made it so 
popular. There can be little doubt that it is its 
thoroughly practical character, the expression 
being used in its best sense. The author under- 
stands what the student ought to learn, and is able 
to put himself in the student's place and to appre- 
ciate his state of mind. — American Chemical Jour- 
nal, April, 1884. 



It is a book on which too much praise cannot be 
bestowed. As a text-book for medical schools it 
is unsurpassable in the present state of chemical 
science, and having been prepared with a special 
view towards medicine and pharmacy, it is alike 
indispensable to all persons engaged in those de- 
partments of science. It includes the whole 
chemistry of thelast Pharmacopceia. — Pacific Medi- 
cal and Surgical Journal, Jan. 1884. 

A text-book which passes through ten editions 



BLOXAM, CHARLES L., 

Professor of Chemistry in King's College, London. 
Chemistry, Inorganic and Organic. New American from the fifth Lon- 
don edition, thoroughly revised and much improved. In one very handsome octavo 
volume of 727 pages, with 292 illustrations. Cloth, $2.00 ; leather, $3:00. 

the best manuals of general chemistry in the Eng- 
lish language. — Detroit Lancet, Feb. 1884. 

We know of no treatise on chemistry which 
cpntains so much practical information in the 
same number of pages. The book can be readily 
adapted not only to the needs of those who desire 
a tolerably complete course of chemistry, but also 
to the needs of those who desire only a general 
knowledge of the subject. We take pleasure in 
recommending this work both as a satisfactory 
text- book, and as a useful book of reference. — Bos- 
ton Medical and Surgical Journal, June 19, 1884. 



Comment from us on this standard work is al- 
most superfluous. It differs widely in scope and 
aim from that of Attfield, and in its way is equally 
beyond criticism. It adopts the most direct meth- 
ods in stating the principles, hypotheses and facts 
of the science. Its language is so terse and lucid, 
and its arrangement of matter so logical in se- 
quence that the student never has occasion to 
complain that chemistry is a hard study. Much 
attention is paid to experimental illustrations of 
chemical principles and phenomena, and the 
mode of conducting these experiments. The book 
maintains the position it has always held as one of 



GREENE, WILLIAM EL., 31. E., 

Demonstrator of Chemistry in the Medical Department of the University of Pennsylvania. 
A Manual of Medical Chemistry. For the use of Students. Based upon Bow* 
man's Medical Chemistry. In one 12mo. volume of 310 pages, with 74 illus. Cloth, $1.75: 
It is a concise manual of three hundred pages, I the recognition of compounds due to pathological 
giving an excellent summary of the best methods conditions. The detection of poisons is treated 
of analyzing the liquids and solids of the body, both with sufficient fulness for the purpose of thestu- 
for the estimation of their normal constituents and | dent or practitioner.— Boston JL of Chem. June,'80. 



10 Lea Brothers & Co.'s Publications — Chemistry 

REMSEN, IRA, M. H., Ph. D., 

Professor of Chemistry in the Johns Hopkins University, Baltimore. 

Principles of Theoretical Chemistry, with special reference to the Constitu- 
tion of Chemical Compounds. New (third) and thoroughly revised edition. In one hand- 
some royal 12mo. volume of 316 pages. Cloth, $2.00. Just ready. 

This work of Dr. Remsen is the very text-book examination of college faculties as the text-book of 
needed, and the medical student who has it at chemical instruction.— St. Louis Medical and Sur- 
his fingers' ends, so to speak, can, if he chooses, giral Journal. January, 1888. 

make himself familiar with any branch of chem- ' It is a healthful sign when we see a demand for 
istry which he may desire to pursue. It would be a third eduk n of such a book as this. This edi- 
difficult indeed to find a more lucid, full, and at tion is larger than the last by about seventy-five 
the same time compact explication of the philos- pages, and much of it has been rewritten, thus 
ophy of chemistry, than the book before us, and bringing it fully abreast of the latest investiga- 
we recommend it to the careful and impartial tions.— If. Y. Medical Journal, Dec. 31, 1887. 

CHARLES, T. CRANSTOUN, M. D., F. C. 8., M. S., 

Formerly Asst. Prof, and Demonst. of Chemistry and Chemical Physics, Queen's College, Belfast. 

The Elements of Physiological and Pathological Chemistry. A 
Handbook for Medical Students and Practitioners. Containing a general account of 
Nutrition, Foods and Digestion, and the Chemistry of the Tissues, Organs, Secretions and 
Excretions of the Body in Health and in Disease. Together with the methods for pre- 
paring or separating their chief constituents, as also for their examination in detail, and 
an outline syllabus of a practical course of instruction for students. In one handsome octavo 
volume of 463 pages, with 38 woodcuts and 1 colored plate. Cloth, $3.50. 

Dr. Charles is fully impressed with the import- nowadays. Dr. Charles has devoted much space 
ance and practical "reach of his subject, and he to the e'lucidation of urinary mysteries. He does 
has treated it in a competent and instructive man- this with much detail, and yet in a practical and 
ner. We cannot recommend a better book than intelligible manner. In fact, the author has filled 
the present. In fact, it fills a gap in medical text- his book with many practical hints.— Medical Rec- 
books, and that is a thing which can rarely be said ord, December 20, 1884. 



HOFFMANN, F., A.M., Ph.D., & BOWER F.B., Ph.D., 

Public Analyst to the State of New York. Prof, of Anal. Chem. in the Phil. Coll. of Pharmacy. 

A Manual of Chemical Analysis, as applied to the Examination of Medicinal 
Chemicals and their Preparations. Being a Guide for the Determination of their Identity 
and Quality, and for the Detection of Impurities and Adulterations. For the use of 
Pharmacists, Physicians, Druggists and Manufacturing Chemists, and Pharmaceutical and 
Medical Students. Third edition, entirely rewritten and much enlarged. In one very 
handsome octavo volume of 621 pages, with 179 illustrations. Cloth, $4.25. 

We congratulate the author on the appearance tion of them singularly explicit. Moreover, it ia 
of the third edition of this work, published for the exceptionally free from typographical errors. We 
first time in this country also. It is admirable and have no hesitation in recommending it to those 
the information it undertakes to supply is both who are engaged either in the manufacture or the 
extensive and trustworthy. The selection of pro- testing of medicinal chemicals.— London Pharma- 
cesses for determining the purity of the substan- ceutical Journal and Transactions, 1883. 
ces of which it treats is excellent and the descrip- | 

CLOWES, FRANK, 2>. Sc, London, 

Senior Science- Master at the High School, Newcastle-under-Lyme, etc. 

An Elementary Treatise on Practical Chemistry and Qualitative 
Inorganic Analysis. Specially adapted for use in the Laboratories of Schools and 
Colleges and by Beginners. Third American from the fourth and revised English edition. 
In one very handsome royal 12mo. volume of 387 pages, with 55 illustrations. Cloth, 
$2.50. 

The style is clear, the language terse and vigor- It is the most readable book of the kind we have 
ous. Beginning with a list of apparatus necessary yet seen, and is without doubt a systematic, 
for chemical work, he gradually unfolds the sub- intelligible and fully equipped laboratory guide 
Ject from its simpler to its more complex divisions, and text-book.— Medical Record, July 18, 1885. 

RALFE, CHARLES H., M. H., F. R. C. P., 

Assistant Physician at the London Hospital. 
Clinical Chemistry. In one pocket-size 12mo. volume of 314 pages, with 16 
illustrations. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 4. 

This is one of the most instructive little works ! cine. Dr. Ralfe is thoroughly acquainted with the 
that we have met with in a long time. The author latest contributions to his science, and it is quite 



is a physician and physiologist, as well as a chem- i refreshing to find the subject dealt with so clearly 
1st, consequently the book is unqualifiedly prac- ' and simply, yet in such evident harmony with the 
tical, telling the physician just what he ought to : modern scientific meth *" 
know, of the applications of chemistry in medi- ; Record, February 2, 1884. 



CLASSEN, ALEXANDER, 

Professor in the Royal Polytechnic School, Aix-la-ChapelU. 
Elementary Quantitative Analysis. Translated, with notes and additions, by 
Edgab F. Smith. Ph. D., Assistant Professor of Chemistry in the Towne Scientific School, 
University of Penna. In one 12mo. volume of 324 pages, with 36 illust. Cloth, $2.00. 

It is probably the best manual of an elementary and then advancing to the analysis of minerals and 
nature extant, insomuch as its methods are the such products as are met with in applied chemis- 
best. It teaches by examples, commencing with try. It is an indispensable book for students in 
single determinations, followed by separations, chemistry.— Boston Journal of Chemistry, Oct. 1878. 



Lea Brothers & Co.'s Publications — Pharm., Mat. Med., Therap. 11 



BRUNTOW, T. LAUDER, M.D., D.Sc, F.R.S., F.R.C.P., 

Lecturer on Materia Medica and Therapeutics at St. Bartholomew's Hospital, London, etc. 

A Text-book of Pharmacology, Therapeutics and Materia Medica ; 

Including the Pharmacy, the Physiological Action and the Therapeutical Uses of Drugs. 
In one handsome octavo volume of 1033 
leather, $6.50. 

It is a scientific treatise worthy to be ranked with 
the highest productions in physiology, either in 
our own or any other language. Everything is 
practical, the dry, hard facts of physiology being 
pressed into service and applied to the treatment 
of the commonest complaints. The information 
is so systematically arranged that it is available 
for immediate use. The index is so carefully 



pages, with 188 illustrations. Cloth, $5.50 ; 

compiled that a reference to any special point is 
at once obtainable. Dr. Brunton is never satisfied 
with vague generalities, but gives clear and pre- 
cise directions for prescribing the various drugs 
and preparations. We congratulate students on 
being at last placed in possession of a scientific 
treatise of enormous practical importance. — The 
London Lancet, June 27, 1885. 



MAISCH, JOHWM., PJiar. D., 

Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. 

A Manual of Organic Materia Medica; Being a Guide to Materia Medica of 
the Vegetable and Animal Kingdoms. For the use of Students, Druggists, Pharmacists 
Physicians. New (3d) edition, thoroughly revised. In one handsome royal 12mo. 



volume of 523 pages, with 257 illustrations. Cloth, $3. Just Beady. 

of a third edition besides saying that it is what 
one would expect from its talented author. The 
arrangement of the subjects is systematic, accord- 
ing to classes. The origin, habitat, description, 
constituents and properties of each drug are given 
in a clear and very succinct manner; and the 
whole book is full of valuable information. The 
work of the publishers is as creditable as that of 
the author, the paper, printing and binding being 
of the highest order of excellence, while the illus- 
trations are superb. — Medical and Surgical Report- 
er, Nov. 19, 1887. 



Prof. Maisch is one of the most distinguished 
pharmacists of this country. He and Prof. Stille 
are the authors of The National Dispensatory, 
which is not excelled by any work of its kind ever 
published. The learning and experience of the 
author, therefore, is a guarantee that his manual 
is well adapted for its purpose, viz.: a text- and 
reference-book for students, pharmacists and phy- 
sicians, containing the most recent and reliable 
information in regard to drugs.— Cincinnati Medi- 
cal News, Nov. 1887. 

This work has already met with so much favor 
that there is little to do in noting the appearance 



BARTHOLOW, ROBERTS, A. M., M. D., LL. £>., 

Professor of Materia Medica and General Therapeutics in the Jeffers'm Medical College of Phila- 
delphia. 

New Remedies of Indigenous Source: Their Physiological Actions and 
Therapeutical Uses. In one octavo volume of about 300 pages. Preparing. 



FARRISH, EDWARD, 

Late Professor of the Theory and Practice of Pharmacy in the Philadelphia College of Pharmacy. 
_ A Treatise on Pharmacy : designed as a Text-book for the Student, and as a 
Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. 
Fifth edition, thoroughly revised, by Thomas S. Wiegand, Ph. G. In one handsome 
octavo volume of 1093 pages, with 256 illustrations. Cloth, $5 ; leather, $6. 



No thorough-going pharmacist will fail to possess 
himself of so useful a guide to practice, and no 
physician who properly estimates the value of an 
accurate knowledge of the remedial agents em- 
ployed by him in daily practice, so far as their 
miscibility, compatibility and most effective meth- 
ods of combination are concerned, can afford to 
leave this work out of the list of their works of 
reference. The country practitioner, who must 
always be in a measure his own pharmacist, will 
find it indispensable.— Louisville Medical News, 
March 29, 1884. 

This well-known work presents itself now based 
upon the recently revised new Pharmacopoeia. 



Each page bears evidence of the care bestowed 
upon it, and conveys valuable information from 
the rich store of the editor's experience. In fact, 
all that relates to practical pharmacy— apparatus, 
processes and dispensing — has been arranged and 
described with clearness in its various aspects, so 
as to afford aid and advice alike to the student and 
to the practical pharmacist. The work is judi- 
ciously illustrated with good woodcuts— American 
Journal of Pharmacy, January, 1884. 

There is nothing to equal Parrish's Pharmacy 
in this or any other language.— London Pharma- 
ceutical Journal. 



HERMANN, Dr. L., 

Professor of Physiology in the University of Zurich. 
Experimental Pharmacology. A Handbook of Methods for Determining the 
Physiological Actions of Drugs. Translated, with the Author's permission, and with 
extensive additions, by Robert Meade Smith, M. D., Demonstrator of Physiology in the 
University of Pennsylvania. In one handsome 12mo. volume of 199 pages, with 32 
illustrations. Cloth, $1.50. 

BRUCE, J. MITCHELL, M. D., F. R. C. P., 

Physician and Lecturer on Materia Medica and Therapeutics at Charing Cross Hospital, London, 
Materia Medica and Therapeutics. An Introduction to Rational Treat- 
ment. Fourth edition. In one pocket-size 12mo. volume of 591 pages. Limp cloth, 
$1.50. See Students' Series of Manuals, page 4. 

GRIFFITH:, ROBERT EGLESFIELD, M. D. 

A Universal Formulary, containing the Methods of Preparing and Adminis- 
tering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceut- 
sits. Third edition, thoroughly revised, with numerous additions ; by John M. Maisch, 
Phar.D., Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. 
In one octavo volume of 775 pages, with 38 illustrations. Cloth, $4.50 ; leather, $5.50. 



12 



Lea Brothers & Co.'s Publications — Mat. Med., Therap. 



8TILLE, A., 3f.L>.,LL.D., & MAISCH, J. M., Phar. D., 

Prof, of Mat. Med. and Botany in Phila. 
College of Pharmacy, Sec 1 y to the Ameri- 
can Pharmaceutical Association. 



Professor Emeritus of the Theory and Prac- 
tice of Medicine and of Clinical Medicine 
in the University of Pennsylvania. 



NEW (FOURTH) EDITION. 

The National Dispensatory. 

CONTAINING THE NATURAL HISTORY. CHEMISTRY, PHARMACY. ACTIONS AND USES OF 

MEDICINES. INCLUDING THOSE RECOGNIZED IN THE PHARMACOPCEIAS OF THE 

UNITED STATES. GREAT BRITAIN AND GERMANY. WITH NUMEROUS 

REFERENCES TO THE FRENCH CODEX. 

Fourth edition revised, and covering the new British Pharmacopoeia. 

In one magnificent imperial octavo volume of 1794 pages, with 311 elaborate 
engravings. Price in cloth, $7.25 : leather, raised bands, $8.00; very handsome half 
Russia, raised bands and open back, $9.00. 

*** This work will be furnished with Patent Ready Reference Thumb-letter Index for $1.00 
in addition to the price in any style of binding. 

In this new edition of The National Dispensatory, all important changes in the 
recent British Pharmacopoeia have been incorporated throughout the volume, while in 
the Addenda will be found, grouped in a convenient section of 24 pages, all therapeutical 
novelties which have been established in professional favor since the publication of the 
third edition two years ago. Detailed information is thus given of the following among 
the many drugs treated: Antipyrin, Cocaine Hydrochlorate, Cascara Sagrada, Fabiana, 
Franciscea, various new Glycerins, Gymnocladus, Hydroquinon, Hypnone, Iodol, Jaca- 
randa, Lanolin, Menthol, Phormium, Sulphophenol, Thallin and Urethan. In this 
edition, as always before, The National Dispensatory may be said to be the represent- 
ative of the most recent state of American, English, German and French Pharmacology, 
Therapeutics and Materia Medica. 



The National Dispensatory is so well and favor- 
ably known on both sides of the Atlantic that 
scarcely anything else is left to the reviewer than 
to call attention to the fact that another edition 
of this valuable work has made its appearance. 
This last edition surpasses even its predecessors 
in thoroughness and accuracy. The fact that in 
1884, when the third edition was published, no 
revision of the British Pharmacopoeia had been 
made for seventeen years, has necessitated a 
thorough going over of the whole work in order 
that references might correspond to the la9t re- 
vision of the work of our British cousins. In 
addition to these changes is a fairly full resume, in 
the form of addenda, of the more important drugs 



which have come into general use in the last two 
or three years. — The American Journal of the Med- 
ical Sciences, April, 1887. 

We think it a matter for congratulation that the 
profession of medicine and that of pharmacy have 
shown such appreciation of this great work as to call 
for four editions within the comparatively brief 
period of eight years. The matters with which it 
deals are of so practical a nature that neither the 
physician nor the pharmacist can do without the 
latest text-books on them, especially those that are 
so accurate and comprehensive as "this one. The 
book is in every way creditable both to the authors 
and to the publishers. — New York Medical Journal, 
May 21, 1887. 



EDES, ROBERT T., M. 2>., 

Jackson Professor of Clinical Medicine in Harvard University, Medical Department. 

A Text-Book of Materia Medica and Therapeutics. In one octavo volume 
of 544 pages. Cloth, $3.50 ; leather, $4.50. Just ready. 

The treatise will be found to be concise and i cine. Such they can find in the present author, 
practical, bringing the subject down to the latest All the newest drugs of promise are treated of. 
developments cf therapeutics and pharmacology, j The clinical index at the end will be found very 
The student and practitioner will find the book a [ useful. We heartily commend the book and con- 
valuable one for reference and study, the former i gratulate the author on having produced so good 
being facilitated by a full and excellent index.— I a one.— N. Y. Medical Journal, Feb. 18, 1888. 
St. Louis Medical and Surgical Journal, Jan. 1888. | Dr. Edes' book represents better than any older 

The present work seems destined to take a prom- | book the practical therapeutics of the present 
inent place as a text-book on the subjects of which J day. The book is a thoroughly practical one. The 



it treats. It possesses all the essentials which we 
expect in a book of its kind, such as conciseness, 
clearness, a judicious classification, and a reason- 
able degree of dogmatism. The style deserves 
the highest commendation for its dignity and 
purity of diction. The student and young practi- 
tioner need a safe guide in this branch of medi- 



cla^sification of remedies has reference to their 
therapeutic action, and such a classification will 
always meet the approval of the student. The rela- 
tive importance of different remedies is indicated 
by the space devoted to each, and by the use of 
larger type in the titles of the more important 
articles. — Pharmaceutical Era, Jan. 1888. 



IARQVBZARSON, ROBERT, M. Z>., 

Lecturer on Materia Medica at St. Mary's Hospital Medical School. 

A Guide to Therapeutics and Materia Medica. Third American edition, 
specially revised by the Author. Enlarged and adapted to the U. S. Pharmacopoeia by 
Frank Woodbury, M. D. In one handsome 12mo. volume of .524 pages. Cloth, $2.25. 



STILLE, ALFRED, M. D., LL. !>., 

Professor of Theory and Practice of Med. and of Clinical Med. in the Univ. of Penna. 

Therapeutics and Materia Medica. A Systematic Treatise on the Action and 
Uses of Medicinal Agents, including their Description and History. Fourth edition, 
revised and enlarged. In two large and handsome octavo volumes, containing 1936 pages. 
Cloth, $10.00 ; leather, $12.00 ; very handsome half Russia, raised bands, $13.00. 



Lea Brothers & Co.'s Publications — Pathol., Histol. 



13 



COATS, JOSEFS, M. D., F. F. P. S., 

Pathologist to the Glasgow Western Infirmary. 
A Treatise on Pathology. In one very handsome octavo volume of 829 pages, 
with 339 beautiful illustrations. Cloth, $5.50 ; leather, $6.50. 

The work before us treats the subject of Path- 
ology more extensively than it is usually treated 
In similar works. Medical students as well as 



physicians, who desire a work for study or refer- 
ence, that treats the subjects in the various de- 
partments in a very thorough manner, but without 
prolixity, will certainly give this one the prefer- 
ence to any with which we are acquainted. It sets 
forth the most recent discoveries, exhibits, in an 
interesting manner, the changes from a normal 
condition effected in structures by disease, and 
points out the characteristics of various morbid 
agencies, so that they can be easily recognized. But, 
not limited to morbid anatomy.it explains fully how 
the functions of organs are disturbed by abnormal 
conditions. There is nothing belonging to its de- 



partmentof medicine that is not as fully elucidated 
as our present knowledge will admit. — Cincinnati 
Medical News, Oct. 1883. 

One of the best features of this treatise consists 
in the judicious admixture of foreign observation 
with private experience. Thus the subject is 
presented in a harmonious manner, facilitating 
the study of single topics and making the entire 
volume profitable and pleasant reading. The 
author includes in his descriptions, general 
pathology as well as the special pathological histol- 
ogy of the different systems and organs. He has 
succeeded in offering to students and practition- 
ers a thoroughly acceptable work.— Medical Record, 
Dec. 22, 1883. 



GREEN, T. HENRY, M. D., 

Lecturer on Pathology and Morbid Anatomy at Charing-Oross Hospital Medical School, London. 

Pathology and. Morbid Anatomy. New (sixth) American from the seventh 
revised and enlarged English edition. In one very handsome octavo volume of about 
500 pages, with about 150 tine engravings. Preparing. 

A notice of the previous edition is appended. 



The fact that this well-known treatise has so 
rapidly reached its sixth edition is a strong evi- 
dence of its popularity. The author is to be con- 
fratulated upon the thoroughness with which he 
as prepared this work. It is thoroughly abreast 
with all the most recent advances in pathology. 



No work in the English language is so admirably 
adapted to the wants of the student and practi- 
tioner as this, and we would recommend it most 
earnestly to every one. — Nashville Journal of Medi- 
cine and Surgery, Nov. 1884. 



WOODHEAD, G. SIMS, M. D., F. R. C. P. E., 

Demonstrator of Pathology in the University of Edinburgh. 
Practical Pathology. A Manual for Students and Practitioners. In one beau- 
tiful octavo volume of 497 pages, with 136 exquisitely colored illustrations. Cloth, $6.00. 



It forms a real guide for the student and practi- 
tioner who is thoroughly in earnest in his en- 
deavor to see for himself and do for himself. To 



the laboratory student it will be a helpftU com- 
themselves with modern methods of examining 



i,'andi 



those who may wish to familiarize 



morbid tissues are strongly urged to provide 
themselves with this manual. The numerous 
drawings are not fancied pictures, or merely 
schematic diagrams, but they represent faithfully 



the actual images seen under the microscope. 
The author merits all praise for having produced 
a valuable work.— Medical Record, May 31, 1884. 

We would heartily recommend it to any student 
who desires to acquaint himself with the subject. 
In the matter we can find nothing to criticise. 
Every point is explained with perfect satisfaction, 
so that the merest tyro may understand. — Physician 
and Surgeon, December, 1883. 



SCHAFER, EDWARD A., F. R. S. 9 

Assistant Professor of Physiology in University College, London. 
The Essentials of Histology. In one octavo volume of 246 pages, with 
281 illustrations. Cloth, $2.25. 

an elementary text-book of histology, comprising 
all the essential facts of the science, but omitting: 
unimportant details. The author has recom- 
mended only those methods upon which long ex- 
perience has proved that full dependence can be 
placed. The strict observance of this plan per- 
mits of no doubt, and makes the work eminently 
satisfactory.— The Physician and Surgeon, July, 1887. 



This admirable work was greatly needed. To 
those who are familiar with the author's former 
"Course of Practical Histology," the book needs 
no recommendation. It has been written with the 
object of supplying the. student with directions 
for the microscopical examination of the tissues, 
which are given in a clear and understandable 
way. Although especially adapted for laboratory 
work, at the same time it is intended to serve as 



KLEIN, E„ M. D., F. R. S., 

Joint Lecturer on General Anat. and Phys. in the Med. School of St. Bartholomew's Hosp., London. 
Elements of Histology. Third edition. In one pocket-size 12mo. volume of 
360 pages, with 181 illus. Limp cloth, $1.50. See Students' Series of Manuals, page 4. 

man body; and, while small in size, it is full to 
overflowing with important facts in regard to these 
multiform and complex structures. We know of 
no book of its size that will prove of greater value 
to medical students and practitioners of medi- 
cine.— The Southern Practitioner, Nov. 1883. 



This little volume, originally intended by its 
able author as a manual for medical students, 
contains much valuable information, systematic- 
ally arranged, that will be acceptable to the 
feneral practitioner. It gives a graphic and lucid 
escription of every tissue and organ in the hu- 



PEPPER, A. J., M. B., M. S., F. R. C. S., 

Surgeon and Lecturer at St. Mary's Hospital, London. 
Surgical Pathology. In one pocket-size 12mo. volume of 511 pages, with 81 
illustrations. Limp cloth, red edges, $2.00. See Students' Series of Manuals, page 4. 

It is not pretentious, but it will serve exceed- 
ingly well as a book of reference. It embodies a 
great deal of matter, extending over the whole 
field of surgical pathology. Its form is practical, 
its language is clear, and the information set 
forth is well-arranged, well-indexed and well- 



illustrated. The student will find in it nothing 
that is unnecessary. The list of subjects cover» 
the whole range of surgery. The book supplies a 
very manifest want and should meet with suc- 
cess. — New York Medical Journal, May 31, 1884. 



Cornil and Ranvier's Pathological Histology. — Translated by E. O. 
Shakespeare, M. D., and J. Henry C. Simes, M. D. Octavo, 800 pp., 360 illustrations. 



14 



Lea Brothers & Co.'s Publications — Practice of Med. 



FLINT, AUSTIN, M. !>., LL. D. 

Prof, of the Principles and Practice of Med. and of Clin. Med. in Bellevve Hospital Medical College, N. 7. 

A Treatise on the Principles and Practice of Medicine. Designed for 
the use of Students and Practitioners of Medicine. New (sixth) edition, thoroughly re- 
vised and rewritten by the Author, assisted by William H. Welch, M. D., Professor of 
Pathology, Johns Hopkins University, Baltimore, and Austin Flint, Jr., M. D., LL. D., 
Professor of Physiology, Bellevue Hospital Medical College, N. Y. In one very handsome 
octavo volume of 1160 pages, with illustrations. Cloth, $5.50; leather, $6.50; very 
handsome half Russia, raised bands, $7.00. 

A new edition of a work of such established rep- I general approval by medical students and practi- 
utationas Flint's Medicine needs but few words to tioners as the work of Professor Flint. In all the 
commend it to notice. It may in truth be said to medical colleges of the United States it is the fa- 



embody the fruit of his labors in clinical medicine, 
ripened by the experience of a long life devoted to 
its pursuit. America may well be proud of having 
produced a man whose indefatigable industry and 
gifts of .genius have done so much to advance med- 
icine ; and all English-reading students must be 
frateful tor the work which he has left behind him. 
t has few equals, either in point of literary excel- 
lence, or of scientific learning, and no one can 
study its pages without being struck by the lu- 
cidity and accuracy which characterize them. It 
is qualities such as these which render it so valu- 
able for its purpose, and give it a foremost place 
among the text-books of this generation 
London Lancet, March 12, 1887. 



vorite work upon Practice; and, as we have stated 
before in alluding to it, there is no other medical 
work that can be so generally found in the libra- 
ries of physicians. In every state and territory 
of thisjvast country the book that will be most likely 
to be found in the office of a medical man, whether 
in city, town, village, or at some cross-roads, is 
Flint's Practice. We make this statement to a 
considerable extent from personal observation, and 
it is the testimony also of others. An examina- 
tion shows that very considerable changes have 
been made in the sixth edition. The work may un- 
doubtedly be regarded as fairly representing the 
The I present state of the science of medicine, and as 
i reflecting the views of those who exemplify in 
No textbook on the principles and practice of] their practice the present stage of progress of med- 
medicine has ever met in this country with such j ical art.— Cincinnati Medical Keu-s, Oct. 1886. 



HARTSHORNE, HENRY, 31. H., LI. D., 

Lately Professor of Hygiene in the University of Pennsylvania. 

Essentials of the Principles and Practice of Medicine. A Handbook 

for Students and Practitioners. Fifth edition, thoroughly revised and rewritten. In one 

royal 12mo. volume of 669 pages, with 144 illustrations. Cloth, $2.75; half bound, $3.00. 

Within the compass of 600 pages it treats of the ' this one; and probably not one writer in our day 



history of medicine, general pathology, general | had a better opportunity than Dr. Hartshorne for 

.and physical diagnosis (including 
laryngoscope, ophthalmoscope, etc.), general ther 



apeutics, nosology, and special pathology and prac- 
tice. There is a wonderful amount of information 
contained in this work, and it is one of the best 
of its kind that we have seen. — Glasgow Medical 
Journal, Nov. 1882. 

An indispensable book. No work ever exhibited 
a better average of actual practical treatment than 



condensing all the views of eminent practitioners 



pr 
into a 12mo. The numerous illustrations will be 
very useful to students especially. These essen- 
tials, as the name suggests, are not intended to 
supersede the text-books of Flint and Bartholow, 
but they are the most valuable in affording the 
means to see at a glance the whole literature of any 
disease, and the most valuable treatment.— Chicago 
Medical Journal and Examiner, April, 1882. 



BRISTOWE, JOHN STEM, M. JD., F. R. C. P., 

Physician and Joint Lecturer on Medicine at St. Thomas' Hospital, London. 
A Treatise on the Practice of Medicine. Second American edition, revised 
by the Author. Edited, with additions, by James H. Hutchinson, M.D., physician to the 
Pennsylvania Hospital. In one handsome octavo volume of 1085 pages, with illustrations. 
Cloth, $5.00; leather, $6.00; very handsome half Russia, raised bands, $6.50. 



The book is a model of conciseness, and com- 
bines, as successfully as one could conceive it to 
be possible, an encyclopaedic character with the 
smallest dimensions. It differs from other admi- 
rable text-books in the completeness with which 
it covers the whole field of medicine. — Michigan 
Medical News, May 10, 1880. 

His accuracy in the portraiture of disease, his 
■care in stating subtle points of diagnosis, and the 
faithfully given pathology of abnormal processes 
have seldom been surpassed. He embraces many 
diseases not usually considered to belong to theory 



and practice, as skin diseases, syphilis and insan- 
ity, but they will not be objected to by readers, as 
he has studied them conscientiously, and drawn 
from the life.— Medical and Surgical Reporter, De- 
cember 20, 1879. 

The reader will find every conceivable subject 
connected with the practice of medicine ably pre- 
sented, in a style at once clear, interesting and 
concise. The additions made by Dr. Hutchinson 
are appropriate and practical, and greatly add to 
its usefulness to American readers. — Buffalo Med- 
ical and Surgical Journal, March, 1880. 



WATSON, SIR THOMAS, M. I)., 

Late Physician in Ordinary to the Queen. 

Lectures on the Principles and Practice of Physic. A new American 
from the fifth English edition. Edited, with additions, and 1 90 illustrations, by Henry 
Hartshorne, A. M., M. D., late Professor of Hygiene in the University of Pennsylvania, 
In two large octavo volumes of 1840 pages. Cloth, $9.00 ; leather, $11.00. 



LECTURES ON THE STUDY OF FEVER. By 
A. Hudson, M. I)., M. It. I. A. In one octavo 
volume of 308 pages. Cloth, ?2.. so. 

A TREATISE ON FEVER. By Robert D. Lyons, 
K. C. C. In one 8vo. vol. of 354 pp. Cloth, 82.26. 



LA ROCHE ON YELLOW FEVER, considered in 
its Historical, Pathological, Etiological and 
Therapeutical Relations. In two large and hand- 
some octavo volumes of 1468 pp. Cloth. 87.00. 



A CENTURY OF AMERICAN MEDICINE, 1776-1876. By Drs. E. H. Clarke, H. J. 

Bioblow, 8. D. Gross, T. G. Thomas, and J. S. Billings. In one 12mo. volume of 370 paj?es. 



Lea Brothers & Co.'s Publications — System of Med. 



15 



For Sale by Subscription Only. 



A System of Practical Medicine. 

BY AMERICAN AUTHORS. 

Edited by WILLIAM PEPPER, M. D., LL. D., 

PROVOST AND PROFESSOR OP THE THEORY AND PRACTICE OP MEDICINE AND OP 
CLINICAL MEDICINE IN THE UNIVERSITY OP PENNSYLVANIA, 

Assisted by Louis Starr, M. D., Clinical Professor of the Diseases of Children in the 
Hospital of the University of Pennsylvania. 

The complete work, in five volumes, containing 5573 pages, with 198 illustrations, is just ready. 
Price per volume, cloth, $5 ; leather, $6 ; half Russia, raised bands and open back, $7. 



In this great work American medicine is for the first time reflected by its worthiest 
teachers, and presented in the full development of the practical utility which is its pre- 
eminent characteristic. The most able men — from the East and the West, from the 
North and the South, from all the prominent centres of education, and from all the 
hospitals which afford special opportunities for study and practice — have united in. 
generous rivalry to bring together this vast aggregate of specialized experience. 

The distinguished editor has so apportioned the work that to each author has beem 
assigned the subject which he is peculiarly fitted to discuss, and in which his views 
will be accepted as the latest expression of scientific and practical knowledge. The 
practitioner will therefore find these volumes a complete, authoritative and unfailing work 
of reference, to which he may at all times turn with full certainty of finding what he needs 
in its most recent aspect, whether he seeks information on the general principles of medi- 
cine, or minute guidance in the treatment of special disease. So wide is the scope of the 
work that, with the exception of midwifery and matters strictly surgical, it embraces the 
whole domain of medicine, including tbe departments for which the physician is accustomed 
to rely on special treatises, such as diseases of women and children, of the genito-urinary 
organs, of the skin, of the nerves, hygiene and sanitary science, and medical ophthalmology 
and otology. Moreover, authors have inserted the formulas which they have found most 
efficient in the treatment of the various affections. It may thus be truly regarded as a 
Complete Library of Practical Medicine, and the general practitioner possessing it 
may feel secure that he will require little else in the daily round of professional duties. 

In spite of every effort to condense the vast amount of practical information fur- 
nished, it has been impossible to present it in less than 5 large octavo volumes, containing 
about 5600 beautifully printed pages, and embodying the matter of about 15 ordinary 
octavos. Illustrations are introduced wherever requisite to elucidate the text. 

A detailed prospectus will be sent to any address on application to the publishers. 



These two volumes bring this admirable work 
to a close, and fully sustain the high standard 
reached by the earlier volumes; we have only 
therefore to echo the eulogium pronounced upon 
them. We would warmly congratulate the editor 
and his collaborators at the conclusion of their 
laborious task on the admirable manner in which, 
from first to last, they have performed their several 
duties. They have succeeded in producing a 
work which will long remain a standard work of 
reference, to which practitioners will look for 

fiidance, and authors will resort to for facts. 
rom a literary point of view, the work is without 
any serious blemish, and in respect of production, 
it has the beautiful finish that Americans always 
give their works. — Edinburgh Medical Journal, Jan. 
1887. 

* * The greatest distinctively American work on 
the practice of medicine, and, indeed, the super- 
lative adjective would not be inappropriate were 
even all other productions placed in comparison. 
An examiuation of the five volumes is sufficient 
to convince one of the magnitude of the enter- 
prise, and of the success which has attended its 
fulfilment.— The Medical Age, July 26, 1886. 

This huge volume forms a fitting close to the 
great system of medicine which in so short a time 
has won so high a place in medical literature, and 
has done such credit to the profession in this 
country. Among the twenty-three contributors 
are the names of the leading neurologists in 
America, and most of the work in the volume is of 
the highest order. — Boston Medical and Surgical 
Journal, July 21, 1887. 

We consider it one of the grandest works on 
Practical Medicine in the English language. It is 
a work of which the profession of this country can 
feel proud. Written exclusively by American 



physicians who are acquainted with all the varie- 
ties of climate in the United States, the character 
of the soil, the manners and customs of the peo- 
ple, etc., it is peculiarly adapted to the wants 
of American practitioners of medicine, and it 
seems to us that every one of them would desire 
to have it. It has been truly called a " Complete 
Library of Practical Medicine," and the general 
practitioner will require little else in his round 
of professional duties. — Cincinnati Medical News. 
March, 1886. 

Each of the volumes is provided with a most 
copious index, and the work altogether promises 
to be one which will add much to the medical 
literature of the present century, and reflect great 
credit upon the scholarship and practical acumen 
of its authors. — The London Lancet, Oct. 3, 1885. 

The feeling of proud satisfaction with which the 
American profession sees this, its representative 
system of practical medicine issued to the medi- 
cal world, is fully justified by the character of the 
work. The entire caste of the system is in keep- 
ing with the best thoughts of the leaders and fol- 
lowers of our home school of medicine, and the 
combination of the scientific study of disease and 
the practical application of exact and experimen- 
tal knowledge to the treatment of human mal- 
adies, makes every one of us share in the pride 
that has welcomed Dr. Pepper's labors. Sheared 
of the prolixity that wearies the readers of the 
German school, the articles glean these same 
fields for all that is valuable. It is the outcome 
of American brains, and is marked throughout 
by much of the sturdy independence of thought 
and originality that is a national characteristic. 
Yet nowhere is there lack of study of the most 
advanced views of the day. — North Carolina Medi- 
cal Journal, Sept. 1886. 



16 Lea Brothers & Co.'s Publications — Clinical Med., etc. 

FOTMERGILL, J. M., M. 2>., Edin,. M. R. C. P., Lond., 

Physician to the City of London Hospital for Diseases of the Chest. 

The Practitioner's Handbook of Treatment ; Or, The Principles of Thera- 
peutics. New (third) edition. In one octavo volume of 661 pages. Cloth, $3.75 ; leather, 
$4.75. Just ready. 

Dr. Fothergill is always interesting and instruct- 1 greatly increased by the introduction of many 
ive, and in this standard work he shows his I prescriptions. That the profession appreciates 

Eeculiar power as a writer on therapeutics to the that the author has undertaken an important work 
est advantage. Everything he undertakes is and has accomplished it is shown by the demand 
done conscientiously. The book well sustains j for this third edition.— New York Medical Journal, 
the favorable impression which it created at the j June 11, 1887. 

beginning of its career, and in its present im- This is a wonderful book. If there be such a 
proved form it will be welcomed more than ever thing as "medicine made easy," this is the work 
by the busy practitioner and the scientific student I to accomplish this result. It imparts information 
of medicine.— The Medical. News, July 23, 1887. J so agreeably, so smoothly, that the reader almost 

To have a description of the normal physiologi- thinks as he lays the book down that he "knew 
cal processes of an organ and of the methods of that before," when in reality he did not, or else he 
treatment of its morbid conditions brought could before have reconciled facts which now 
together in a single chapter, and the relations ! become clear as daylight. The author deals with 
between the two clearly stated, cannot fail to prove the "Principles of Therapeutics" the study of 
a great convenience to many thoughtful but busy which will give great vantage to the physician.— 
physicians. The practical value of the volume is | Virginia Medical Monthly, June, 1887. 

REYNOLDS, J. RUSSELL, M. L>., 

Professor of the Principles and Practice of Medicine in University College, London. 
A System of Medicine. With notes and additions by Henry Hartshorne, 
A. M., M. P., late Professor of Hygiene in the University of Pennsylvania. In three large 
and handsome octavo volumes, containing 3056 double-columned pages, with 317 illustra- 
tions. Price per volume, cloth, $5.00 ; sheep, $6.00; very handsome half Russia, raised bands, 
$6.50. Per set, cloth, $15; leather, $18; half Russia, $19.50. Sold only by subscription. 

STILLE, ALFRED, M. !>., LL. !>., 

Professor Emeritus of the Theory and Practice of Med. and of Clinical Med. in the Univ. of Penna. 
Cholera : Its Origin, History, Causation, Symptoms, Lesions, Prevention and Treat- 
ment. In one handsome 12mo. volume of 163 pages, with a chart. Cloth, $1.25. 



FINLAYSON, JAMES, M. L>., Editor, 

Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary, etc. 

Clinical Manual for the Study of Medical Cases. With Chapters 
by Prof. Gairdner on the Physiognomy of Disease; Prof. Stephenson on Diseases of 
the Female Organs; Dr. Robertson on Insanity; Dr. Gemmell on Physical Diagnosis; 
Dr. Coats on Laryngoscopy and Post-Mortem Examinations, and by the Editor on Case- 
taking, Family History and Symptoms of Disorder in the Various Systems. New edition. 
In one 12mo. volume of 682 pages, with 158 illustrations. Cloth, $2.50. 

The profession cannot but welcome the second 
edition of this very valuable work of Finlayson 
and his collaborators. The size of the book has 
been increased and the number of illustrations 
nearly doubled. The manner in which the sub- 
ject is treated is a most practical one. Symptoms 



alone and their diagnostic indications form the 
basis of discussion. The text explains clearly and 
thoroughly the methods of examination and the 
conclusions to be drawn from the physical signs. 
The Medical News, April 23, 1887 



and a study of means to the end which cannot 
fail in laying an excellent foundation for the 
student for future success as an able diagnostician. 
—Medical Record, August 13, 1887. 

The second edition of this manual is a very 
considerable improvement upon the first. Much 
new matter has been introduced and the work has 
been brought up to the present time in all respects. 
As it stands it is one of the best manuals of diag- 
nosis in the English language for beginners. The 
whole work is so complete and so simply written, 



This manual is one of the most complete and j and yet contains such an amount of valuable 
perfect of its kind. It goes thoroughly into the j information, that it should be a part of the library 

Question of diagnosis from every possible point. | of every practitioner.— New York Medical Journal, 
t must lead to a thoroughness of observation, an ; July 23, 1887. 
examination in detail of every scientific appliance, | 



FENWICK, SAMUEL, M. £>., 

Assistant Physician to the London Hospital. 

The Student's Guide to Medical Diagnosis. From the third revised and 
enlarged English edition. In one very handsome royal 12mo. volume of 328 pages, with 
87 illustrations on wood. Cloth, $2.25! 

MABERSHOJST, S. O., M. D., 

Senior Physician to and late Led. on Principles and Practice of Med. at Guy's Hospital, London. 

On the Diseases of the Abdomen ; Comprising those of the Stomach, and 
other parts of the Alimentary Canal, CEsophagus, Caecum, Intestines and Peritoneum. Second 
American from third enlarged and revised English edition. In one handsome octavo 
volume of 554 pages, with illustrations. Cloth, $3.50. 



TANKER, TJIOMAS IIAWKES, M. 2>. 

A Manual of Clinical Medicine and Physical Diagnosis. Third American 
from the second London edition. Revised and enlarged by Tilbury Fox, M. D. 
In one small 12mo. volume of 362 pages, with illustrations. Cloth, $1.50. 



Lea Brothers & Co.'s Publications — Hygiene, Electr., Pract. 17 



BABTHOLOW, BOBEBTS, A. M., M. ID., LL. JD. y 

Prof, of Materia Medica and General Therapeutics in the Jefferson Med. Coll. of Phila., etc. 
Medical Electricity. A Practical Treatise on the Applications of Electricity 
to Medicine and Surgery. New (third) edition. In one very handsome octavo volume of 
308 pages, with 110 illustrations. Cloth, $2.50. 



The fact that this work has reached its third edi- 
tion in six years, and that it has been kept fully 
abreast with the increasing use and knowledge of 
electricity,demonstrates its claim to be considered 
a practical treatise of tried value to the profession. 
The matter added to the present edition embraces 
the most recent advances in electrical treatment. 
The illustrations are abundant and clear, and the 
work constitutes a full, clear and concise manual 
well adapted to the needs of both student and 
practitioner.— The Medical News, May 14, 1887. 

This "practical treatise on the applications of 
electricity to medicine and surgery" has grown to 
be so important a work that every practitioner 



should read it, especially when it is recalled what 
possibilities lie in the path of the further study of 
the therapeutics of electricity. Dr. Bartholow has 
here presented the profession with a concise work 
that, beginning with elementary descriptions and 
principles, gradually grows, page by page, into a 
magnificently practical treatise, describing opera- 
tions in detail, and giving records of successes 
that prove electricity to be marvellous as a curative 
agent in many forms of disease. The doctor can- 
not now do better than to possess himself of Dr. 
Bartholow's treatise, just as it is.— Virginia Medi- 
cal Monthly, June, 1887. 



BLCHABDSON, B. W., M.D., LL. I>., F.B.S., 

Fellow of the Royal College ot Physicians, London. 
Preventive Medicine. In one octavo volume of 729 pages. Cloth, f 4; leather, 
$5 ; very handsome half Kussia, raised bands, $5.50. 

tive collection of data upon the diseases common 



Dr. Richardson has succeeded in producing a 
work which is elevated in conception, comprehen- 
sive in scope, scientific in character, systematic in 
arrangement, and which is written in a clear, con- 
cise and pleasant manner. He evinces the happy 
faculty of extracting the pith of what is known on 
the subject, and of presenting it in a most simple, 
Intelligent and practical form. There is perhaps 
no similar work written for the general public 
that contains such a complete, reliable and instruc- 



to the race, their origins, causes, and the measures 
for their prevention. The descriptions of diseases 
are clear, chaste and scholarly ; the discussion of 
the question of disease is comprehensive, masterly 
and fully abreast with the latest and best knowl- 
on the subject, and the preventive measures 



American Journal o. 



ate, exp 
rf 'the Mec 



edical Sciences, April, 1884. 



HABTSHOBNE, HENBY, M. &., LL. D., 

Formerly Professor of Hygiene in the University of Pennsylvania, and Professor of Physiology and 
Diseases of Children in the Woman's Medical College of Pennsylvania. 

A Household Manual of Medicine, Surgery, Nursing and Hygiene: 
For Daily Use in the Preservation of Health and Care of the Sick and Injured, with an 
Introductory Outline of Anatomy and Physiology. In one very handsome royal octavo 
volume of 946 pages, with 8 plates and 283 engravings. Cloth, $4.00 ; very handsome 
full red leather, $5.00. 

THE YEAB-BOOK OF TBEATMENT FOB 1887. 

A Comprehensive and Critical Review for Practitioners of Medi- 
cine. In one 12mo. volume of 341 pages, bound in limp cloth, $1.25. Just ready. 



THE YEAB-BOOK OF TBEATMENT FOB 1886. 

Similar to that of 1887 above. 12mo., 320 pages. Limp cloth, $1.25. 

This "review" includes every department of 
medical and surgical as well as obstetrical practice. 
It attempts nothing in the way of etiology, diag- 
nosis or symptoms, but limits itself to the ad- 
vances made in the treatment of diseases, injuries, 
etc. The work seems to us to be invaluable to 



every practitioner, whether he be. a general one or 
a specialist. It is a book to be kept on the office 
table for continuous reference. An excellent in- 
dex to subjects, as well as to authors quoted, is 
appended. — Virginia Medical Monthly, April, 1887. 



#*£ For special commutations with periodicals see page 3. 

SCHBEIBEB, JOB. JOSEPH. 

A Manual of Treatment by Massage and Methodical Muscle Ex- 
ercise. Translated by Walter Mendelson, M. D., of New York. In one handsome 
octavo volume of 274 pages, with 117 fine engravings. Just ready. Cloth, $2.75. 

The present volume will do much to establish 
mechanical therapeutics upon a scientific basis. 
The work is a very welcome addition to the library, 



and we heartily recommend it to our readei 
a step in the right direction.— New York Medical 
Journal, July 16, 1887. 
As a thorough and satisfactory exposition of the 



science of mechanical therapeutics, adapted to 
the use of the general practitioner, this volume 
leaves nothing to be desired. The text is fully 
illustrated by well-drawn woodcuts, leaving no 
room for obscurity in the description of the vari- 
ous manipulations recommended.— Atlanta Medi- 
cal and Surgical Journal, Aug. 18S7. 



STURGES' INTRODUCTION TO THE STUDY 
OP CLINICAL MEDICINE. Being a Guide to 
the Investigation of Disease. In one handsome 
12mo. volume of 127 pages. Cloth, $1.25. 

DAVIS' CLINICAL LECTURES ON VARIOUS 
IMPORTANT DISEASES. By N. S. Davis, 
M. D. Edited by Fkank H. Davis, M. D. Second 
edition. 12mo. 287 pages. Cloth, $1.76. 

TODD'S CLINICAL LECTURES ON CERTAIN 
ACUTE DISEASES. In one octavo volume of 
320 pages. Cloth, $2.50. 



PAVY'S TREATISE ON THE FUNCTION OF DI- 
GESTION; its Disorders and their Treatment. 
From the second London edition. In one octavo 
volume of 238 pages. Cloth. $2.00. 

BARLOW'S MANUAL OF THE PRACTICE OF 
MEDICINE. With additions by D. F. Condije, 
M.D. 1 vol. 8vo., pp. 603. Cloth, $2.50. 

CHAMBERS' MANUAL OF DIET AND REGIMEN 
IN HEALTH AND SICKNESS. In one hand- 
some octavo volume of 302 pp. Cloth, $2.75. 

HOLLAND'S MEDICAL NOTES AND REFLEC- 
TIONS. 1 vol. 8vo., pp. 493. Cloth, $3.50. 



18 Lea Brothers & Co.'s Publications — Throat, Lungs, Heart. 
FLINT, AUSTIN, M. JD., 

Professor of the Principles and Practice of Medicine in Bellevue Hospital Medical College, N. 7. 

A Manual of Auscultation and Percussion ; Of the Physical Diagnosis of 
Diseases of the Lungs and Heart, and of Thoracic Aneurism. Fourth edition. In one 
handsome royal 12mo. volume of 278 pages, with 14 illustrations. Cloth, $1.75. 

This admirable little book is too well known to I ciated. We ourselves have used a former edition 
require any extended notice. That a third and : as a text-book in teaching the physical examina- 
large edition has been exhausted in little more tion of the chest, and can consequently speak from 
than two years, is evidence that the book is appre- | experience.— Boston Med. and Sur. Jour., Feb. 11,'86. 



B 7 THE SAME A UTHOR. 

Physical Exploration of the Lungs by Means of Auscultation and 
Percussion. Three lectures delivered before the Philadelphia County Medical Society, 
1882-83. In one handsome small 12mo. volume of 83 pages. Cloth, $1.00. 

A Practical Treatise on the Physical Exploration of the Chest and 
the Diagnosis of Diseases Affecting the Respiratory Organs. Second and 
revised edition. In one handsome octavo volume of 591 pages. Cloth, $4.50. 

Phthisis: Its Morbid Anatomy, Etiology, Symptomatic Events and 
Complications, Fatality and Prognosis, Treatment and Physical Diag- 
nosis ; In a series of Clinical Studies. In one handsome octavo volume of 442 pages. 
Cloth, $3.50. 

A Practical Treatise on the Diagnosis, Pathology and Treatment of 
Diseases of the Heart. Second revised and enlarged edition. In one octavo volume 
of 550 pages, with a plate. Cloth, $4. 

Essays on Conservative Medicine and Kindred Topics. In one very hand- 
some royal 12mo. volume of 210 pages. Cloth, $1.38. 

BROWNE, LENNOX, F. R. C. S., E., 

Senior Physician to the Central London Throat and Ear Hospital. 

A Practical Guide to Diseases of the Throat and Nose, including 
Associated Affections of the Ear. With 120 illustrations in color, and 200 en- 
gravings on wood designed and executed by the Author. New (second) and enlarged 
edition. In one imperial octavo volume of about 600 pages. Cloth, $6. Just ready. 

Among the points to which we would especially | In this edition the letter-press has been trebled, 
draw the attention of the practitioner, is the sys- ! the engravings have been quadrupled, and twenty- 
tem followed in describing the symptoms and ■ two new colored illustrations have been added, 
methods of treatment in the various forms of j We can cordially recommend all our readers to 
throat disease, the very valuable record of typical j procure this work and avail themselves of the 
cases culled from the author's practice, and a rich treasures of practical experience therein 
valuable appendix of formulae useful in treatment, collected.— Provincial Medical Journal, Dec. 1, 1887. 

GROSS, S. !>., M.D., LL.JD., B.C.L. Oxon., LL.D. Cantab. 

A Practical Treatise on Foreign Bodies in the Air-passages. In one 

octavo volume of 452 pages, with 59 illustrations. Cloth, $2.75. 

COHEN, J. SOLIS, M. D., 

Lecturer on Laryngoscopy and Diseases of the Throat and Chest in the Jefferson Medical College. 

Diseases of the Throat and Nasal Passages. A Guide to the Diagnosis and 
Treatment of Affections of the Pharynx, (Esophagus, Trachea, Larynx and Nares. Third 
edition, thoroughly revised and rewritten, with a large number of new illustrations. In 
one very handsome octavo volume. Preparing. 

SEILER, CARL, M. JD., 

Lecturer on Laryngoscopy in the University of Pennsylvania. 

A Handbook of Diagnosis and Treatment of Diseases of the Throat, 
Nose and Naso-Pharynx. Second edition. In one handsome royal 12mo. volume 
of 294 pages, with 77 illustrations. Cloth, $1.75. 



BROADBENT, W. H., M. JO., F. R. C. JP., 

Physician to and Lecturer on Medicine at St. Mary's Hospital. 
The Pulse. In one 12mo. volume. Preparing. See Series of Clinical Manuals, page 4. 



FULLER ON DISEASES OF THE LUNGS AND I SMITH ON CONSUMPTION; its Early andReme- 
AIR-PASSAGES. Their Pathology, Physical Di- diable Stages. 1 vol. 8vo., pp. 253. Cloth, $2.26. 
agnosis, Symptoms and Treatment. From the LA ROCHE ON PNEUMONIA. 1 vol. 8vo. of 490 
second and revised English edition. In one pages. Cloth, 83-00. 
octavo volume of 475 pages. Cloth, $3.50. WILLIAMS ON PULMONARY CONSUMPTION; 

BLADE ON DIPHTHERIA; its Nature and Treat- I its Nature, Varieties and Treatment. With an 
ment, with an account of the History of its Pre- i analysis of one thousand cases to exemplify its 
valence in various Countries. Second and revised duration. In one 8vo. vol. of 303 pp. Cloth, $2.50. 
edition. In one 12mo. vol., pp. 158. Cloth, $1.25. JONES' CLINICAL OBSERVATIONS ON FUNC- 

WALSHE ON THE DISEASES OF THE HEART TIONAL NERVOUS DISORDERS. Second Am- 
AND GREAT VESSELS. Third American edi- erican edition. In one handsome octavo volume 
tion. In 1 vol. 8vo., 416 pp. Cloth, $3.00. | of 340 pages. Cloth, $3.25. 



Lea Brothers & Co.'s Publications — Nerv. and Ment. Dis., etc. 19 



MOSS, JAMES, M.JD., F.R.C.P., LL.JD., 

Senior Assistant Physician to the Manchester Royal Infirmary. 

A Handbook on Diseases of the Nervous System. In one octavo 
volume of 725 pages, with 184 illustrations. Cloth, $4.50 ; leather, $5.50. 



This admirable work is intended for students of 
medicine and for such medical men as have no time 
for lengthy treatises. In the present instance the 
duty of arranging the vast store of material at the 
disposal of the author, and of abridging the de- 
scription of the different aspects of nervous dis- 
eases, has been performed with singular skill, and 
the result is a concise and philosophical guide to 



the department of medicine of which it treats. 
Dr. Ross holds such a high scientific position that 
any writings which bear his name are naturally 
expected to have the impress of a powerful intel- 
lect. In every part this handbook merits tne 
highest praise, and will no doubt be found of the 
greatest value to the student as well as to the prac- 
titioner.— Edinburgh Medical Journal, Jan. 1887. 



MITCHELL, S. WEIR, M. L>., 

Physician to Orthopaedic Hospital and the Infirmary for Diseases of the Nervous System, Phila., etc. 

Lectures on Diseases of the Nervous System; Especially in Women. 



Second edition. In one 12mo. volume of 

No work in our language develops or displays 
more features of that many-sided affection, hys- 
teria, or gives clearer directions for its differen- 
tiation, or sounder suggestions relative to its 
general management and treatment. The book 
is particularly valuable in that it represents in 
the main the author's own clinical studies, which 
have been so extensive and fruitful as to give his 



pages. Cloth, $1.75. 
teachings the stamp of authority all over the 
realm of medicine. The work, although written 
by a specialist, has no exclusive character, and 
the general practitioner above all others will find 
its perusal profitable, since it deals with diseases 
which he frequently encounters and must essay 
to treat. — American Practitioner, August, 1885. 



HAMILTON, ALLAN McLAJSE, M. &., 

Attending Physician at the Hospital for Epileptics and Paralytics, BlackwelVs Island, N. F. 
Nervous Diseases ; Their Description and Treatment. Second edition, thoroughly 
revised and rewritten. In one octavo volume of 598 pages, with 72 illustrations. Cloth, $4. 



When the first edition of this good book appeared 
we gave it our emphatic endorsement, and the 

E resent edition enhances our appreciation of the 
ook and its author as a safe guide to students of 
clinical neurology. One of the best and most 
critical of English neurological journals, Brain, has 



characterized this book as the best of its kind in 
any language, which is a handsome endorsement 
from an exalted source. The improvements in the 
new edition, and the additions to it, will justify its 
purchase even by those who possess the old.— 
Alienist and Neurologist, April, 1882. 



TTTKE, DANIEL HACK, M. V., 

Joint Author of The Manual of Psychological Medicine, etc. 

Illustrations of the Influence of the Mind upon the Body in Health 
and Disease. Designed to elucidate the Action of the Imagination. New edition. 
Thoroughly revised and rewritten. In one handsome octavo volume of 467 pages, with 
two colored plates. Cloth, $3.00. 

method of interpretation. Guided by an enlight- 
ened deduction, the author has reclaimed for 
science a most interesting domain in psychology, 
previously abandoned to charlatans and empirics. 
This book, well conceived and well written, must 
commend itself to every thoughtful understand- 
ing.— New York Medical Journal, September 6, 1884. 



It is impossible to peruse these interesting chap- 
ters without being convinced of the author's per- 
fect sincerity, impartiality, and thorough mental 
grasp. Dr. Tuke has exhibited the requisite 
amount of scientific address on all occasions, and 
the more intricate the phenomena the more firmly 
has he adhered to a physiological and rational 



CLOUSTON, THOMAS S., M. D., F. It. C. P., L. R. C. S., 

Lecturer on Mental Diseases in the University of Edinburgh. 

Clinical Lectures on Mental Diseases. With an Appendix, containing an 
Abstract of the Statutes of the United States and of the Several States and Territories re- 
lating to the Custody of the Insane. By Charles F. Folsom, M. D., Assistant Professor 
of Mental Diseases, Med. Dep. of Harvard Univ. In one handsome octavo volume of 541 
pages, with eight lithographic plates, four of which are beautifully colored. Cloth, $4. 

The practitioner as well as the student will ac- 
cept the plain, practical teaching of the author as a 
forward step in the literature of insanity. It is 
refreshing to find a physician of Dr. Clouston's 
experience and high reputation giving the bed- 
side notes upon which his experience has been 



upon which his experience 
founded and his mature judgment established, 
Such clinical observations cannot but be useful to 
B@?*Dr. Folsom's Abstract may also b 
108 pages. Cloth, $1.50. 



the general practitioner in guiding him to a diag- 
nosis and indicating the treatment, especially in 
many obscure and doubtful cases of mental dis- 
ease. To the American reader Dr. Folsom's Ap- 
pendix adds greatly to the value of the work, and 
will make it a desirable addition to every library. 
— American Psychological Journal, July, 1884. 

obtained separately in one octavo volume of 



SAVAGE, GEORGE H., M. D., 

Lecturer on Mental Diseases at Guy's Hospital, London. 
Insanity and Allied Neuroses, Practical and Clinical. In one 12mo. 
of 551 pages, with 18 illus. Cloth, $2.00 See Series of Clinical Manuals, page 4. 

PLAYFAIR, W. S., M. ID., F. R. C. P. 

The Systematic Treatment of Nerve Prostration and Hysteria. 

one handsome small 12mo. volume of 97 pages. Cloth, $1.00. 

Blandford on Insanity and its Treatment: Lectures on the Treatment, 

Medical and Legal, of Insane Patients. In one very handsome octavo volume. 



vol. 



In 



20 



Lea Brothers & Co.'s Publications— Surgery. 



ASHHURST, JOHN, Jr., M. D., 

Professor of Clinical Surgery, Untv. of Penna., Surgeon to the Episcopal Hospital, Philadelphia. 

The Principles and Practice of Surgery. New (fourth) edition, enlarged 
and revised, in one large and handsome octavo volume of 1114 pages, with 597 illustra- 
tions. Cloth, $6 ; leather, $7 ; half Russia, $7.50. 



As with Erichsen so with Ashhurst, its position 
in professional favor is established, and one has 
now but to notice the changes, if any, in theory 
and practice, that are apparent in the present 
as compared with the preceding edition, published 
three years ago. The work has been brought well 



Every advance in surgery worth notice, chroni- 
cled in recent literature, has been suitably recog- 
nized and noted in its proper place. Suffice it to- 
say, we regard Ashhurst's Surgery, as now pre- 
sented in the fourth edition, as the best single 
volume on surgery published in the English lan- 



up to date, and is larger and better illustrated than guage, valuable alike to the student and the prac 
before, and its author may rest assured that it will titioner, to the one as a text-book, to the other as 
certainly have a "continuance of the favor with a manual of practical surgery. With pleasure we 
which it has heretofore been received."— The , give this volume our endorsement in full.— New 
American Journal of the Medical Sciences, Jan. 1886. I Orleans Medical and Surgical Journal, Jan., 1886. 



GJROSS, S. D., M. D., LL. D., D. C. L. Oxon., LL. D. 
Cantab., 

Emeritus Professor of Surgery in the Jefferson Medical College of Philadelphia. 
A System of Surgery: Pathological, Diagnostic, Therapeutic and Operative. 
Sixth edition, thoroughly revised and greatly improved. In two large and beautifully- 
printed imperial octavo volumes containing 2382 pages, illustrated by 1623 engravings. 
Strongly bound in leather, raised bands, $15 ; half Russia, raised bands, $16. 

Dr. Gross' System of Surgery has long been the I His System o1 Surgery, which, since its first edi- 
standard work on that subject for students and I tion in 1859, has been a standard work in this 
practitioners.— London Lancet, May 10, 1884. country as well as in America, in "the whole 

The work as a whole needs no commendation, domain of surgery," tells how earnest and labor!- 
Many years ago it earned for itself the enviable ous and wise a surgeon he was. how thoroughly 
reputation of the leading American work on sur- he appreciated the work done by men in other 
gery. and it is still capable of maintaining that countries, and how much he contributed to pro- 
standard. A considerable amount of new material mote the science and practice of surgery in his 
has been introduced, and altogether the distin- own. There has been no man to whom America 
guished author has reason to lie satisfied that he is so much indebted in this respect as the Nestor 
has placed the work fully abreast of the state of of surgery.— British Medical Journal, May 10, 1884. 
our knowledge.— Med. Record, Nov. 18, 1882. 



DRUITT, ROBERT, 31. R. C. S., etc. 

Manual of Modern Surgery. Twelfth edition, thoroughly revised by Stan- 
ley Boyd, M. B., B. S., F. R. C. S. In one 8vo. volume of 965 pages, with 373 illustra- 
tions. Cloth, $4 ; leather, $5. 



It is essentially a new book, rewritten from be- 
ginning to end. The editor has brought his work 
up to the latest date, and nearly every subject on 
which the student and practitioner would desire 
to consult a surgical volume, has found its place 
here. The volume closes with about twenty pages 



Druitt's Surgery has been an exceedingly popu- 
lar work in the profession. It is stated that 50,000 
copies have been sold in England, while in the 
United States, ever since its first issue, it has been 
used as a text-book to a very large extent. Dur- 
ing the late war in this country it was so highly 



of formulae covering a broad range of practical i appreciated that a copy was issued by the Govern- 
therapeutics. The student will find that the new ment to each surgeon. The present edition, while 
Druitt is to this generation what the old one was it has the same features peculiar to the work at 
to the former, and no higher praise need be first, embodies all recent discoveries in surgery, 
accorded to any volume,— Aorth Carolina Medical I and is fully up to the times. Cincinnati Medical 
Journal, October, 1887. I News, September, 1887. 

BALL, CHARLES B., M. Ch., Dub., F. B. C. S. E., 

Surgeon and Teacher at Sir P. Dun's Hospital, Dublin. 

Diseases of the Rectum and Anus. In one 12mo. volume of 417 pages, 
with 54 engravings and 4 colored plates Cloth, $2.25. Just ready. See Series of Clinical 
Manuals, page 4. 



It is a pleasure to read an exhaustive and well- 
arranged book, such as the one before us. It 
covers all the ground, and yet is written in a terse 
and concise style that makes it exceedingly good 
reading. The work is far in advance of the ordi- 
nary text-book on this specialty. It is very com- 



plete, and the matter is all of practical importance 
and well arranged. The writer has done for rectal 
surgery what Treves in the companion volume 
has done for intestinal obstruction, and both 
works are alike creditable.— N. Y. Medical Journal, 
Jan. 28, 1888. 



GIBNEY, V. P., 31. D., 

Surgeon to the Orthopaedic Hospital, New York, etc. 

Orthopaedic Surgery. For the use of Practitioners and Students, 
some octavo volume, profusely illustrated. Preparing. 



In one hand- 



ROBEBTS, JOHN B., A. 31., M. D., 

Lecturer on Anatomy and on Operative Surgery at the Philadelphia School of Anatomy. 

The Principles and Practice of Modern Surgery. For the use of Students- 
and Practitioners of Medicine and Surgery. In one very handsome octavo volume of about 
500 pages, with many illustrations. Preparing. 



BELLAMY, EDWARD, F. R. C. S., 

Surgeon and Lecturer on Surgery at Charing Cross Hospital, London. 
Operative Surgery. Shortly. See Students? Series of Manuals, page 4. 



Lea Brothers & Co.'s Publications — Surgery. 



21 



ERICHSEN, JOHN E., F. R. S., F. R. C. S., 

Professor of Surgery in University College, London, etc. 
The Science and Art of Surgery ; Being a Treatise on Surgical Injuries, Dis- 
eases and Operations. From the eighth and enlarged English edition. In two large and 
beautiful octavo volumes of 2316 pages, illustrated with 984 engravings on wood. 
Cloth, $9; leather, raised bands, $11 ; half Eussia, raised bands, $12. 



In noticing the eighth edition of this well- 
known work, it would appear superfluous to say 
more than that it has, like its predecessors, been 
brought fully up to the times, and is in conse- 
quence one of the best treatises upon surgery that 
has ever been penned by one man. We have al- 
ways regarded "The Science and Art of Surgery" 
as one of the best surgical text-books in the 
English language, and this eighth edition only 
confirms our previous opinion. We take great 
pleasure in cordially commending it to our read- 
ers.— The Medical News, April 11, 1885. 

After being before the profession for thirty 



years and maintaining during that period a re- 
putation as a leading work on surgery, there is noi 
much to be said in the way of comment or criti- 
cism. That it still holds its own goes without say- 
ing. The author infuses into it his large experi- 
ence and ripe judgment. Wedded to no school, 
committed to no theory, biassed by no hobby, he 
imparts an honest personality in his observations, 
and his teachings are the rulings of an impartial 
judge. Such men are always safe guides, and their 
works stand the tests of time and experience. 
Such an author is Erichsen, and such a work ishia 
Surgery.— Medical Record, Feb. 21, 1885. 



BRYANT, THOMAS, F. R. C. S., 

Surgeon and Lecturer on Surgery at Guy's Hospital, London. 
The Practice of Surgery. Fourth American from the fourth and revised Eng- 
lish edition. In one large and very handsome imperial octavo volume of 1040 pages, with 
727 illustrations. Cloth, $6.50 ; leather, $7.50 ; half Kussia, $8.00. 

The fourth edition of this work is fully abreast 
of the times. The author handles his subjects 
with that degree of judgment and skill which is 
attained by years of patient toil and varied ex- 
perience. The present edition is a thorough re- 
vision of those which preceded it, with much new 
matter added. His diction is so graceful and 
logical, and his explanations are so lucid, as to 
place the work among the highest order of text- 



books for the medical student. Almost every 
topic in surgery is presented in such a form as to 
enable the busy practitioner to review any subject 
in every-day practice in a short time. No time is 
lost with useless theories or superfluous verbiage. 
In short, the work is eminently clear, logical and 
practical. — Chicago Medical Journal arid Examiner, 
April, 1886. 



TREVES, FREDERICK, F. R. C. S., 

Hunterian Professor at the Royal College of Surgeons of England. 
A Manual of Surgery. In Treatises by Various Authors. In three 12mo. 
volumes, containing 1866 pages, with 213 engravings. Price per volume, cloth, $2. See 
Students' Series of Manuals, page 4. 



We have here the opinions of thirty-three 
authors, in an encycloptedic form for easy and 
ready reference. The three volumes embrace 
every variety of surgical affections likely to be 
met with, the paragraphs are short and pithy, and 
the salient points and the beginnings of new sub- 
jects are always printed in extra-heavy tyj>e, so 
that a person may find whatever information he 
may be in need of at a moment's glance.— Cin- 
cinnati Lancet-Clinic, August 21, 1886. 

The hand of Mr. Treves is evident throughout 



in the choice, arrangement and logical sequence of 
the subjects. Every topic, as far as observed, is 
treated with a fulness or essential detail, which is 
somewhat surprising. Another characteristic of the 
work is the well-nigh universal acceptance of mod- 
ern and progressive views of pathology and treat- 
ment. The entire work is conceived and executed 
in a scientific spirit. It contains the bone and mar- 
row of modern surgery.— Annals of Surgery, Oct. 



BUTLIJST, HE JVM Y T., F. R. C. S., 

Assistant Surgeon to St. Bartholomew's Hospital, London. 
Diseases of the Tongue. In one 12mo. volume of 456 pages, with 
plates and 3 woodcuts. Cloth, $3.50. See Series of Clinical Manuals, page 4. 



colored 



The language of the text is clear and concise. 
The author has aimed to state facts rather than to 
express opinions, and has compressed within the 
compass of this small volume the pathology, etiol- 
ogy, etc., of diseases of the tongue that are incon- 



veniently scattered through general works on sur- 
gery and the practice of medicine. The physician 
and surgeon will appreciate its value as an aid and 
guide. — Physician and Surgeon, Sept. 1886. 



TREVES, FREDERICK, F. R. C. S., 

Surgeon to and Lecturer on Surgery at the London Hospital. 

Intestinal Obstruction. In one pocket-size 12mo. volume of 522 pages, with 60 
illustrations. Limp cloth, blue edges, $2.00. See Series of Clinical Manuals, page 4. 



A standard work on a subject that has not been 
10 comprehensively treated by any contemporary 
English writer. Its completeness renders a full 
review difficult, since every chapter deserves mi- 
nute attention, and it is impossible to do thorough 



justice to the author in a few paragraphs. Intes- 
tinal Obstruction is a work that will prove of 
equal value to the practitioner, the student, the 
pathologist, the physician and the operating sur- 
geon.— British Medical Journal, Jan. 31, 1885. 



GOUID, A. FEARCE, M. S., M. B., F. R. C. S„ 

Assistant Surgeon to Middlesex Hospital. 

Elements of Surgical Diagnosis. In one pocket-size 12mo. volume of 589 
pages. Cloth, $2.00. See Students' Series of Manuals, page 4. 



PIRRIE'S PRINCIPLES AND PRACTICE OF 
SURGERY. Edited by John Neill, M. D. In 
one 8vo. vol. of 784 pp. with 316 illus. Cloth, 83.75. 

MILLER'S PRACTICE OF SURGERY. Fourth 
and revised American from the last Edinburgh 
edition. In one large 8vo. vol. of 682 pages, with 
364 illustrations. Cloth, $3.75. 



SKEY'S OPERATIVE SURGERY. In one vol. 8vo. 

of 661 pages, with 81 woodcuts. Cloth, $3.25. 
MILLER'S PRINCIPLES OF SURGERY. Fourth 
American from the third Edinburgh edition. In 
one 8vo. vol. of 638 pages, with 340 illustrations. 
Cloth, $3.75. 



22 Lea Brothers & Co.'s Publications — Surgery, Frac, Disloc. 
HOLMES, TIMOTHY, M. A., 

Surgeon arid Lecturer on Surgery at St. George's Hospital,, London. 

A System of Surgery ; Theoretical and Practical. IN TREATISES BY 
VARIOUS AUTHORS. American edition, thoroughly revised and re-edited 
by John H. Packard, M. D., Surgeon to the Episcopal and St. Joseph's HospitalB, 
Philadelphia, assisted by a corps of thirty-three of the most eminent American surgeons. 
In three large and very handsome imperial octavo volumes containing 3137 double- 
OOiOmned pages, with 979 illustrations on wood and 13 lithographic plates, beautifully 
colored. Price per set, cloth, $18.00; leather, $21.00; half Russia, $22.50. Sold only by 
subscription. 

HAMILTON, FRANK H., M. JD. 9 LL. D., 

Surgeon to Bellevue Hospital, New York. 

A Practical Treatise on Fractures and Dislocations. Seventh edition 
thoroughly revised and much improved. In one very handsome octavo volume of 998 
pages, with 379 illustrations. Cloth, $5.50 ; leather, $6.50 ; very handsome half Russia, 
open back, $7.00. 

It is about twenty-five years ago since the first I any lengthened review. We can only say that it 
edition of this great work appeared. The edition is still unapproached as a treatise, and that it is a 
now issued is the seventh, and this fact alone is i proof of the zeal and industry and great ability of 
enough to testify to the excellence of it in all par- , its distinguished author.— The Dublin Journal of 
ticulars. Books upon special subjects do not [ Medical Science, Feb. 1886. 

usually command extended sale, but this one is ! His famous treatise on Fractures and Dislcca- 
without a rival in any language. It is essentially j tions, published first in 18G0, is justly regarded as 
a practical treatise, and it gathers within its covers ; the best book on that subject in existence. It has 
almost everything valuable that has been written : now run through seven editions, and has been 
about fractures and dislocations. The principles ' translated into French and German.— Medical 
and methods of treatment are very fully given. | Record, Aug. 14, 1886. 
The book is so well known that it does not require I 



SMITH, STEPHEN, M. JD., 

Professor of Clinical Surgery in the University of the City of New York. 

The Principles and Practice of Operative Surgery. New (second) and 
thoroughly revised edition. In one very handsome octavo volume of 892 pages, with 
1005 illustrations. Cloth, $4.00; leather," $5.00. Just ready. 

We have never come across a work upon surgery require any words of commendation, and its mer- 
that we have considered better adapted to the its effectually protect it from adverse criticism, 
wants of the medical man and student. It is , It is a treatise upon the principles as well as the 
replete with information of the most valuable, practice of mechanical surgery. The subject mat- 
practical character, of a kind just fitted to the ter is brought down to the very latest period, hence 
wants of the every-day practitioner. Having been we shall find the work to be a faithful exponent 
thoroughly revised and partly rewritten, it has of the art of surgery as practised now. Stephen 
the merit of being fully abreast of the times in Smith's Operative Surgery is one of the mostcom- 
presenting the latest accepted views on all surgical plete works in the English language. The descrip- 
matters. —Cincinnati Medical yens, March, 1887. tions of operative procedures are plain.— The 

This work is too well and too favorably known to American Journal of the Medical Sciences, April, 1887. 

STIMSON, LEWIS A., B. A., M.'I>., 

Surgeon to the Presbyterian and Bellevue Hospitals, Professor of Clinical Surgery in the Medical 
Faculty of the University of the City of New York, Corresponding Member of the Societe de 
Chirurgie of Paris. 

A Manual of Operative Surgery. New (second) edition. In one very hand- 
some royal 12mo. volume of 503 pages, with 342 illustrations. Cloth, $2.50. 

There is always room for a good book, so that | effected in operative methods and procedures by 
while many works on operative surgery must be i the antiseptic system, and has added an account 
considered superfluous, that of Dr. Stimson has j of many new operations and variations in the 
held its own. The author knows the difficult art steps of older operations. We do not desire to 
of condensation. Thus the manual serves as a ! extol this manual above many excellent standard 
work of reference, and at the same time as a j British publications of the same class, still we be- 
handy guide. It teaches what it professes, the lieve that it contains much that is worthy of imi- 
eteps of operations. In this edition Dr. Stimson tation.— British Medical Journal, Jan. 22, 1887. 
has sought to indicate the changes that have been | 

By the same Author. 
A Treatise on Fractures and Dislocations. In two handsome octavo vol- 
umes. Vol. I., Fractures, 582 pages, 360 beautiful illustrations. Vol. II., Disloca- 
tions, 540 pages, with 1(53 illustrations. Complete work just ready, cloth, $5.50; leather, 
$7.50. Either volume separately, cloth, 83.00; leather, $4.00. 

The author has given to the medical profession I ough. The chapters on repair of fractures and their 
in this treatise on fractures what is likely to be- treatment show him not only to be a profound stu- 
come a standard work on the subject. It is certainly dent, but likewise a practical surgeon andpatholo- 
not surpassed by any work written in the English, gist. His mode of treatment of the different fract- 
or, for that matter, any other language. The au- uresis eminently sound and practical. We consider 
th'or tells us in a short, concise and comprehensive this work one of the best on fractures ; and it will 
manner.all that is known about his subject. There be welcomed not onlv as a text-book, but also by 
is nothing scanty or superficial about it, as in most the surgeon in full practice. — N. (). Medical and 
other treatises; on the contrary, everything is thor- | Surgical Journal, March, 1883. 

MARSH, HOWARD, F. R. C. S., 

Senior Assistant Surgeon to and Lecturer on Anatomy at St. Bartholometc's Hospital, London. 

Diseases of the Joints. In one 12mo. volume of 468 pages, with 64 woodcuts 
and a colored plate. Cloth, $2.00. See Series of Clinical Manuals, page 4. 

PICK, T. PICKERING, F. R. C. S., 

Surgeon to and Lecturer on Surqt ry it St. George's Hospital, London. 

Fractures and Dislocations. In one 12mo. volume of 530 pages, with 93 
illustrations. Limp cloth, §2.00. .See Series of Clinical Manuals, page 4. 



Lea Brothers & Co.'s Publications — Otol., Ophthal. 23 

BURNETT, CHARLES H., A. M., M. D.,~ 

Professor of Otology in the Philadelphia Polyclinic; President of the American Otological Society. 

The Ear, Its Anatomy, Physiology and Diseases. A Practical Treatise 
for the use of Medical Students and Practitioners. New (second) edition. In one handsome 
octavo volume of 580 pages, with 107 illustrations. Cloth, $4.00 ; leather, $5.00. 

We note with pleasure the appearance of a second carried out, and much new matter added. Dr. 
edition of this valuable work. When it first came Burnett's work must be regarded as a very valua- 
out it was accepted by the profession as one of ble contribution to aural surgery, not only on 
the standard works on modern aural surgery in account of its comprehensiveness, but because it 
the English language ; and in his second edition contains the results of the careful personal observa- 
Dr. Burnett has fully maintained his reputation, tion and experience of this eminent aural surgeon. 
for the book is replete with valuable information —London Lancet, Feb. 21, 1885. 
and suggestions. The revision has been carefully 



FOLITZER, An AM, 

Imperial-Royal Prof, of Awral Therap. in the Univ. of Vienna. 
A Text-Book of the Ear and its Diseases. Translated, at the Author's re- 
quest, by James Patterson Cassells, M. D., M. E. C. S. In one handsome octavo vol- 
ume of 800 pages, with 257 original illustrations. Cloth, $5.50. 

section, and this again by the pathological physi- 
ology, an arrangement which serves to keep up the 
interest of the student by showing the direct ap- 
plication of what has preceded to the study of dis- 
ease. The whole work can be recommended as a 
reliable guide to the student, and an efficient aid 
to the practitioner in his treatment. — Boston Med- 
ical and Surgical Journal, June 7, 1883. 



The work itself we do not hesitate to pronounce 
the best upon the subject of aural diseases which 
has ever appeared, systematic without being too 
diffuse on obsolete subjects, and eminently prac- 
tical in every sense. The anatomical descriptions 
of each separate division of the ear are admirable, 
and profusely illustrated by woodcuts. They are 
followed immediately by the physiology of the 



JTTLER, HENRY E., E. R. C. S., 

Senior AssH Surgeon, Royal Westminster Ophthalmic Hosp. ; late Clinical Ass't, Moorflelds, London. 

A Handbook of Ophthalmic Science and Practice. In one handsome 
octavo volume of 460 pages, with 125 woodcuts, 27 colored plates, selections from the 
Test-types of Jaeger and Snellen, and Holmgren's Color-blindness Test. Cloth, $4.50 ; 
leather, $5.50. 

NETTLESHIF, EDWARD, F. R. C. S., 

Ophthalmic Surg, and Led. on Ophth. Surg, at St. Thomas' Hospital, London. 

The Student's Guide to Diseases of the Eye. New (third) edition, thor- 
oughly revised. With a chapter on the Detection of Color-Blindness, by William 
Thomson, M. D., Professor of Ophthalmology in the Jefferson Medical College. In one 
12mo. volume of 479 pages, with 164 illust., test-types and formula. Cloth, $2. Just ready. 



In the small work before us we have combined 
simplicity of description with thoroughness of 
instruction. It is such a book as any intelligent 
student can read with profit to himself.— St. Louis 
Medical and Surgical Journal, Oct. 1887. 

This excellent and trustworthy manual is ad- 



dressed to students, but is equally suited to the 
needs of practitioners, who will find in its pages 
much valuable instruction. The style of the au- 
thor is pleasant, and the matter of his book is 
admirable. — Medical and Surgical Reporter, Oct. 1, 



NORRIS, WM. F., M. D., and OLIVER, CHAS. A., M. D. 

Clin. Prof, of Ophthalmology in Univ. of Pa. 

A Text-Book of Ophthalmology. In one octavo volume of about 500 pages, 
with illustrations. Preparing. 

CARTER, R. BRUDENELL, & FROST, W. ADAMS, 

F. R. C. S., F. R. C. S., 

Ophthalmic Surgeon to and Lecturer on Oph- Assistant Ophthalmic Surgeon to and Joint 

thalmic Surgery at St. George's Hospital, Lecturer on Ophthalmic Surgery at St. 

London. George's Hospital, London. 

Ophthalmic Surgery. In one 12mo. volume of 559 pages, with 91 woodcuts, 
color blindness test, test-types and dots and appendix of formulae. Just ready. Cloth, 
$2.25. See Series of Clinical Manuals, page 4. 

WEEDS, J. SOELBERG, F. R. C. S„ 

Professor of Ophthalmology in Kinq's College Hospital, London, etc. 

A Treatise on Diseases of the Eye. New (fifth) American from the third 
London edition. In one large octavo volume. Preparing. 

BROWNE, EDGAR A., 

Surgeon to the Liverpool Eye and Ear Infirmary and to the Dispensary for Skin Diseases. 
How to Use the Ophthalmoscope. Being Elementary Instructions in Oph- 
thalmoscopy, arranged for the use of Students. In one small royal 12mo. volume of 116 
pages, with 35 illustrations. Cloth, $1.00. 



LAURENCE AND MOON'S HANDY BOOK OF 
OPHTHALMIC SURGERY, for the use of Prac- 
titioners. Second edition. In one octavo vol- 
ume of 227 pages, with 65 illust. Cloth, $2.75. 



LAWSON ON INJURIES TO THE EYE, ORBIT 
AND EYELIDS: Their Immediate and Remote 
Effects. 8 vo., 404 pp., 92 illus. Cloth, $3.50. 



24 Lea Brothers & Co.'s Publications — Urin. Dis., Dentistry, etc. 
ROBERTS, WILLIAM, M. D., 

Lecturer on Medicine in the Manchester School of Medicine, etc. 

A Practical Treatise on Urinary and Renal Diseases, including Uri- 
nary Deposits. Fourth American from the fourth London edition. In one hand- 
some octavo volume of 609 pages, with 81 illustrations. Cloth, $3.50. 

The previous editions of this book have made it The peculiar value aud finish of the book are in 
so familiar to and so highly esteemed by the med- a measure derived from its resolute maintenance 
ical public, that little more is necessary than a of a clinical and practical character. It is an un- 
mere announcement of the appearance of this, rivalled exposition of everything which relates 
their successor. But it is pleasant to be able to directly or indirectly to the diagnosis, prognosis 
sav that, good as those were, this is still better, and treatment of urinary diseases, and possesses 
In* fact, we think it may be said to be the best book a completeness not found elsewhere in our lan- 
ln print on the subject of which it treats.— The guage in its account of the different affections.— 
American Journal of the Medical Sciences.— Jan. 1886. The Manchester Medical Chronicle, July, 1886. 

FURDY, CHARLIES W., M. D. 

Bright's Disease and Allied Affections of the Kidneys. In one octavo 
volume of 288 pages, with illustrations. Cloth, $2. 

The object of this work is to " furnish a system- short space the theories, facts and treatments, and 
atic, practical and concise description of the going more fully into their later developments, 
pathology and treatment of the chief organic On treatment the writer is particularly strong, 
diseases "of the kidney associated with albuminu- steering clear of generalities, and seldom omit- 
ria, whi^I) shall represent the most recent ad- ting, what text-books usually do, the unimportant 
vances in our knowledge on these subjects ;" and items which are all important to the general prao- 
this definition of the object is a fair description of titioner. — The Manchester Medical Chronicle, Oct., 
the book. The work is a useful one, giving in a | 1886. 



MORRIS, HENRY, M. B., F. R. C. S., 

Surgeon to and Lecturer on Surgery at Middlesex Hospital, London. 

Surgical Diseases of the Kidney. In one 12mo. volume of 554 pages, with 40 
woodcuts, and 6 colored plates. Limp cloth, $2.25. See Series of Clinical Manuals, page 4. 
In this manual we have a distinct addition to I he took in hand. It is a full and trustworthy 
surgical literature, which gives information not ' book of reference, both for students and prac- 
elsewhere to be met with in a single work. Such \ tiuoners in search of guidance. The illustrations 
a book was distinctly required, and Mr. Morris , in the text and the chromo-lithographs are beau- 
has very diligently and ably performed the task j tifully executed.— The London Lancet, Feb. 26, 1886. 

LUCAS, CLEMENT, M. B.^B. S., F. R. C. S., 

Senior Assistant Surgeon to &u\/s Hospital, London. 
Diseases of the Urethra. In one 12mo. volume. Preparing. See Series 
of Clinical Manuals, page 4. 

THOMPSON, SIR HENRY, 

Surgeon and Professor of Clinical Surgery to University College Hospital, London. 

Lectures on Diseases of the Urinary Organs. Second American from the 
third English edition. In one 8vo. volume of 203 pp., with 25 illustrations. Cloth, $2.25. 

By the Same Author. 
On the Pathology and Treatment of Stricture of the Urethra and 
Urinary Fistulse. From the third English edition. In one octavo volume of 359 
pages, with 47 cuts and 3 plates. Cloth, $3.50. 

THE AMERICAN SYSTEM OF DENTISTRY. 

In Treatises by Various Authors. Edited by Wilbur F. Litch, M. D., 
D. D. S., Professor of Prosthetic Dentistry, Materia Medica and Therapeutics in the 
Pennsylvania College of Dental Surgery. In three very handsome octavo volumes con- 
taining 3100 pages, with 1863 illustrations and 9 full page plates. Per volume, cloth, $6 ; 
leather, $7 ; half Morocco, gilt top, $8. The complete work is now ready. For sale by 
subscription only. 
As an encyclopaedia of Dentistry it has no su- | doubtless it is), to mark an epoch in the history of 

fierior. It should form a part of every dentist's dentistry. Dentists will be satisfied with it and 
ibrary, as the information it contains is of the proud of it— they must. It is sure to be precisely 
freatest value to all engaged in the practice <>f what the student needs to put him and keep him 
entistry. — American Journal of Dental Science, in the right track, while the profession at large 
September, 1886. will receive incalculable benefit from it.— Odonto- 

A grand system, big enough and good enough graphic Journal, Jan. 1887. 
and handsome enough for a monument (which | 

COLEMAN, A., L. R. C. J?., F. R. C. S., Exam. L. I). S., 

Dent. Surg, and Led. on Dent. Sure/, at St. Bartholomew's Hosp. and the Dent. Hosp., London. 

A Manual of Dental Surgery and Pathology. Thoroughly revised and 

adapted to the use of American Students, by Thomas C. STELLWAGEN, M. A., M. D., 
D. D. S., Prof, of Physiology at the Philadelphia Dental College. In one handsome octavo 
volume of 412 pages, with 331 illustrations. Cloth, $3.25. 

ES MARCH, Dr. FMUEDRICH, 

Professor of Surgery at the University of Kiel, etc. 

Early Aid in injuries and Accidents. Five Ambulance Lectures. Trans- 
lated by H. R. H. Princess Christian. In one handsome small 12mo. volume of 109 
pages, with 24 illustrations. Cloth, 75 cents. 

BASHAM ON RENAL DISEASES: A Clinical I one 12mo. vol. of 304 pages, with 21 illustration*. 
Guide to their Diagnosis and Treatment. In | Cloth. 82.00. 



Lea Brothers & Co.'s Publications — Venereal, Impotence. 



25 



GROSS, SAMUEL W., A. M., M. JD., LL. U., 

Professor of the Principles of Surgery and of Clinical Surgery in the Jefferson Medical College of Phila. 

A Practical Treatise on Impotence, Sterility, and Allied Disorders 
of the Male Sexual Organs. New (third) edition, thoroughly revised. In one very 
handsome octavo volume of 163 pages, with 16 illustrations. Cloth, $1.50. 
We must congratulate the author that another | that it has been translated into Russian may indi< 



edition has been made necessary. The tone of 
the book is healthy, and a cheerful prognosis is 
given of many of the affections of which it treats. 
We feel confident that the book will continue to 
sell on its merits.— N. Y. Med. Journal, June 18, 1887. 
It must be gratifying to both author and pub- 
lishers that large first and second editions of this 
little work were so soon exhausted, while the fact 



cate that it filled a void even in foreign literature. 
His is a careful and physiological study of the 
sexual act, so far as concerns the male, and all 
his conclusions are scientifically reached. The 
book has a place by itself in our literature, and 
furnishes a large fund of information concerning 
important matters that are too often passed over 
in silence.— The Medical Press, June, 1887. 



BTJMSTEAI), F. J., 

M. JD., LL. D., 

Late Professor of Venereal Diseases 
at the College of Physicians and 
Surgeons, New York, etc. 



and TAYLOR, R. W., 

A. M., M. n., 

Surgeon to Charity Hospital, New York, Prof, of 
Venereal and Skin Diseases in the University of 
Vermont, Pres. of the Am. Dermatological Ass'n. 

The Pathology and Treatment of Venereal Diseases. Including the 
results of recent investigations upon the subject. Fifth edition, revised and largely re- 
written, by Dr. Taylor. In one large and handsome octavo volume of 898 pages with 
139 illustrations, and thirteen chromo-lithographic figures. Cloth, $4.75 ; leather, $5.75 ; 
very handsome half Russia, $6.25. 



It is a splendid record of honest labor, wide 
research, just comparison, careful scrutiny and 
original experience, which will always be held as 
a high credit to American medical literature. This 
Is not only the best work in the English language 
upon the subjects of which it treats, but also one 
which has no equal in other tongues for its clear, 
comprehensive and practical handling of its 
themes.— Am. Jour, of the Med. Sciences, Jan, 1884. 

It is certainly the best single treatise on vene- 
real in our own, and probably the best in any lan- 
guage.— Boston Med. and Surg. Journal, April 3, 1884. 

The character of this standard work is so well 



known that it would be superfluous here to pass in 
review its general or special points of excellence. 
The verdict of the profession has been passed; it 
has been accepted as the most thorough and com- 
plete exposition of the pathology and treatment of 
venereal diseases in the language. Admirable as a 
model of clear description, an exponent of sound 
pathological doctrine, and a guide for rational and 
successful treatment, it is an ornament to the medi- 
cal literature of this country. The additions made 
to the present edition are eminently judicious, 
from the standpoint of practical utility. — Journal of 
Cutaneous and Venereal Diseases, Jan. 1884. 



CORNIL, F., 

Professor to the Faculty of Medicine of Paris, and Physician to the Lour cine Hospital. 

Syphilis, its Morbid Anatomy, Diagnosis and Treatment. Specially 
revised by the Author, and translated with notes and additions by J. Henry C. Simes, 
M. D., Demonstrator of Pathological Histology in the University of Pennsylvania, and 
J. William White, M. D., Lecturer on Venereal Diseases and Demonstrator of Surgery 
in the University of Pennsylvania. In one handsome octavo volume of 461 pages, with 
84 very beautiful illustrations. Cloth, $3.75. 

The anatomy, the histology, the pathology and 
the clinical features of syphilis are represented in 
this work in their best, most practical and most 
instructive form, and no one will rise from its 



perusal without the feeling that his grasp of the 
wide and important subject on which it treats is 
a stronger and surer one. — The London Practi- 
tioner, Jan. 1882. 



HUTCHINSON, JONATHAN, F. R. S., F. R. C. S., 

Consulting Surgeon to the London Hospital. 
Syphilis. In one 12mo. volume of 542 pages, with 8 chromo-lithographs. 
$2.25. See Series of Clinical Manuals, page 4. 



Cloth, 



Those who have seen most of the disease and 
those who have felt the real difficulties of diagno- 
sis and treatment will most highly appreciate the 
facts and suggestions which abound in these 
pages. It is a worthy and valuable record, not 
only of Mr. Hutchinson's very large experience 



and power of observation, but of his patience and 
assiduity in taking notes of his cases and keep- 
ing them in a form available for such excellent 
use as he has put them to in this volume.— London 
Medical. Record, Nov. 12, 1887. 



GROSS, S. JD., M. JD., LL. JD., JD. C. L., etc. 

A Practical Treatise on the Diseases, Injuries and Malformations 
of the Urinary Bladder, the Prostate Gland and the Urethra. Third 
edition, thoroughly revised by Samuel W. Gross, M. D. In one octavo volume of 574 
pages, with 170 illustrations. Cloth, $4.50. 

CULLFRIFR, A., & BUMSTFAJD, F. J., M.JD., LL.JD., 

Surgeon to the Hdpital du Midi. Late Professor of Venereal Diseases in the College of Physicians 

and Surgeons, New York. 

An Atlas of Venereal Diseases. Translated and edited by Freeman J. Btjm- 
stead, M. D. In one imperial 4to. volume of 328 pages, double-columns, with 26 plates, 
containing about 150 figures, beautifully colored, many of them the size of life. Strongly 
bound in cloth, $17.00. A specimen of the plates and text sent by mail, on receipt of 25 cts. 

HILL ON SYPHILIS AND LOCAL CONTAGIOUS I FORMS OF LOCAL DISEASE AFFECTING 

DISORDERS. In one 8vo vol. of 479 p. Cloth, $3.25. PRINCIPALLY THE ORGANS OF GENERA - 

LEE'S LECTURES ON SYPHILIS AND SOME | TION. In one 8vo. vol. of 246 pages. Cloth, $2.26. 



26 Lea Brothers & Co.'s Publications — Venereal, Skin. 

TAYLOR, ROBERT W., A.M., M. D., 

Surgeon to Charity Hospital, New York, and to the Department of Venereal and Skin Diseases of 
the New Y->rk Hospital. 

A Clinical Atlas of Venereal and Skin Diseases: Including Diagnosis, 
Prognosis and Treatment. In eight large folio parts, measuring 14 x 18 inches, and 
comprising 58 beautifully-colored plates with 192 figures, 65 engravings and 400 pages 
of text. Price per part, $2.50. Parts I. and II. shortly. For sale by subscription only. 
Specimen plates sent on receipt of 10 cents. 

The early appearance of this great work will mark an era in the history of its subjects. 
It will afford to all English-speaking practitioners and specialists their first opportunity 
of procuring a work in which life-like pictures of all venereal and skin diseases are 
accompanied by a text altogether satisfactory on the practical side of these troublesome 
affections. Other distinguishing features of this Atlas will be the abundance and size 
of its colored plates, and the beauty of their execution. Being chosen with a view to 
presenting typical cases rather than mere medical curiosities, they will furnish a vivid 
and ready means of recognizing the various affections as they appear in life. The text 
will be principally confined to a terse and definite staiement of diagnosis and treatment, 
and it will be further illustrated by a large number of engravings executed in a size and 
style thoroughly in keeping with the nature of the work. The Atlas will be sold by 
subscription only, and in due course every member of the profession will be personally 
visited and offered an opportunity to procure this most useful addition to his working 
library. A full prospectus is now ready for distribution on application. 



KAPOSI, MORIZ, 

Of Vienna. 

The Pathology and Treatment of Diseases of the Skin. For the use 

of Practitioners and Students. Translated, with the author's permission, by W Xavier 
Sudduth, M. D., F. R. M. S. In one octavo volume of about 600 pages, with 74 engrav- 
ings and 8 colored plates. Preparing. 

HYDE, J. NEVINS, A. M., M. I)., 

Professor of Dermatology and Venereal Diseases in Rush Medical College, Chicago. 

A Practical Treatise on Diseases of the Skin. For the use of Students and 
Practitioners. New (second) edition. In one handsome octavo volume of about 600 
pages, with 2 colored plates and 85 beautiful and elaborate illustrations. Just ready. 
Cloth, $4.50 ; leather, $5.50. 

A few notices of the previous edition are appended : 



The author has given the student and practi 
tioner a work admirably adapted to the wants of 
each. We can heartily commend the book as a 
valuable addition to our literature and a reliable 
guide to students and practitioners in their studies 
and practice.— Am. Journ. uf Med. Sci., July, 1883. 

The aim of the author has been to present to his 
readers a work not only expounding the most 
modern conceptions of his subject, but presenting 
what is of standard value. He has more especially 
devoted its pages to the treatment of disease, and 



by his detailed descriptions of therapeutic meas- 
ures has adapted them to the needs of the physi- 
cian in active practice. In dealing with these 
questions the author leaves nothing to the pre- 
sumed knowledge of the reader, but enters thor- 
oughly into the most minute descripjipn, so that 
one is not only told what should be done under 
given conditions but how to do it as well. It is 
therefore in the best sense "a practical treatise." 
That it is comprehensive, a glance at the index 
will show.— Maryland Medical Journal, July 7, 1883. 



FOX, T., M.D., F.R.C.JP.,and FOX, T.C.,B.A., 3I.R.C.S., 

Physician to the Department for Skin Diseases, Physician for Diseases of the Skin to the 

University College Hospital, London. Westminster Hospital, London. 

An Epitome of Skin Diseases. With Formulae. For Students and Prac- 
titioners. Third edition, revised and enlarged. In one very handsome 12ino. volume 
of 238 pages. Cloth, $1 .25. 

The third edition of this convenient handbook | manual to lie upon the table for instant reference, 
calls for notice owing to the revision and expansion | Its alphabetical arrangement is suited to this use, 
which it has undergone. The arrangement of skin I for all one has to know is the name of the disease, 
diseases in alphabetical order, which is the method and here are its description and the appropriate 
of classification adopted in this work, becomes a treatment at hand and ready for instant applica- 
positive advantage to the student. The book is tion. The present edition has been very carefully 
one which we can strongly recommend, not only revised and a number of new diseases are de- 
to students but also to practitioners who require a scribed, while most of the recent additions to 
compendious summary of the present state of dermal therapeutics find mention, and the formu- 
dermatology— British Medical Journal, July 2, 1883. lary at the end of the book has been considerably 

We cordially recommend Fox's Epitome to those augmented.— The Medical News, December, 1883. 
whose time is limited and who wish a handy 



WILSON, ERASMUS, F. R. S. 

The Student's Book of Cutaneous Medicine and Diseases of the Skin. 

In one handsome small octavo volume of 535 pages. Cloth, $3.50. 



SILLIER, TH03IAS, M. JO., 

Physician to the Skin Department of University College, London. 
Handbook of Skin Diseases; for Students and Practitioners. Second Ameri- 
can edition. In one 12mo. volume of 353 pages, with plates. Cloth, $2.25. 



Lea Brothers & Co.'s Publications — Ois. of Women. 



27 



The American Systems of Gynecology and Obstetrics. 

Systems of Gynecology and Obstetrics, in Treatises by American 
Authors. Gynecology edited by Matthew D. Mann, A. M., M. D., Professor of Obstetrics 
and Gynecology in the Medical Department of the University of Buffalo; and Obstet- 
rics edited by Barton Cooke Hirst, M. D., Obstetrician to the Philadelphia and to the 
Maternity Hospitals, Philadelphia. In four very handsome octavo volumes of about 800 
pages each, fully illustrated by wood engravings and colored plates. Volume I. of the 
Gynecology, containing 784 pages, with 201 engravings on wood and 3 colored plates, is 
noiv ready. Volume I. of the Obstetrics ready shortly. The subsequent volumes are to 
follow at regular intervals. Prices per volume: Cloth, $5.00; leather, $6.00 ; half Russia, 
$7.00. For sale by subscription only. Address the Publishers. Full descriptive circular 
free on application. 

LIST OF CONTRIBUTORS. 



WILLIAM H. BAKER, M. D., 
ROBERT BATTEY, M. D., 
SAMUEL C BUSEY, M. D., 
JAMES C CAMERON, M. D., 
HENRY C. COE, A. M., M. D., 
E. C. DUDLEY, A. B., M. D., 
EDWARD S. DUNSTER, M. D., 
B. McE. EMMET, M. D., 
GEORGE J. ENGELMANN, M. D., 
HAROLD C. ERNST, M. D., 
HENRY J. GARR1GUES, A. M., M. D., 
WILLIAM GOODELL, A. M., M. D., 
EGBERT H. GRANDIN, A. M., M. D., 
CHARLES M. GREEN, M. D., 
SAMUEL W. GROSS, M. D., 
ROBERT P. HARRIS, M. D., 
GEORGE T. HARRISON, M. D., 
BARTON C. HIRST, M. D. 
STEPHEN Y. HOWELL, M. D., 
A. REEVES JACKSON, A. M., M. D., 
W. W. JAGGARD, M. D., 
EDWARD W. JENKS, M. D., LL. D., 
In our notice of the "System of Practical Medi- 
cine by American Authors," we made the follow- 
ing statement: — "It is a work of which the Dro- 
fession in this country can feel proud. Written 
exclusively by American physicians who are ac- 
quainted with all the varieties of climate in the 
United States, the character of the soil, the man- 
ners and customs of the people, etc., it is pecul- 
iarly adapted to the wants of American practition- 
ers of medicine, and it seems to us that every one 
of them would desire to have it." Every word 
thus expressed in i-pgard to the "American Sys- 
tem of Practical Medicine" is applicable to the 
"System of Gynecology by American Authors," 



HOWARD A. KELLY, M. D., 
CHARLES CARROLL LEE, M. D., 
WILLIAM T. LUSK, M. D., LL. D., 
MATTHEW D. MANN, A. M., M. D., 
H. NEWELL MARTIN, F. R. S., M. D., 

D.Sc, M.A., 
RICHARD B. MAURY, M. D., 
C. D. PALMER, M. D., 
ROSWELL PARK, M. D., 
THEOPHILUS PARVIN, M. D., LL. D., 
R. A. F. PENROSE, M. D., LL. D., 
THADDEUS A. REAMY, A. M., M. D., 
J. C. REEVE, M. D., 
WILLIAM L. RICHARDSON, M. D., 
A. D. ROCKWELL, A. M., M. D., 
ALEXANDER J. C. SKENE, M. D., 
J. LEWIS SMITH, M. D., 
R. STANSBURY SUTTON, A. M., M. D., 

LL. D., 
T. GAILLARD THOMAS, M. D., LL. D., 
ELY VAN DE WARKER, M. D., 
W. GILL WYLIE, M. D. 
which we desire now to bring to the attention of 
our readers. It, like the other, has been written 
exclusively by American physicians who are 
acquainted with all the characteristics of American 
people, who are well informed in regard to the 
peculiarities of American women, their manners, 
customs, modes of living, etc. As every practis- 
ing physician is called upon to treat diseases of 
females, and as they constitute a class to which 
the familly physician must give attention, and 
cannot pass over to a specialist, we do not know of 
a work in any department of medicine that we 
should so strongly recommend medical men gen- 
erally purchasing. — Cincinnati Med. Neivs, July,1887. 



THOMAS, T. GAILLARI), M. D., 

Professor of Diseases of Women in the College of Physicians and Surgeons, N. F. 

A Practical Treatise on the Diseases of Women. Fifth edition, thoroughly 
revised and rewritten. In one large and handsome octavo volume of 810 pages, with 266 
illustrations. Cloth, $5.00 ; leather, $6.00 ; very handsome half Russia, raised bands, $6.50. 



The words which follow " fifth edition" are in 
this case no mere formal announcement. The 
alterations and additions which have been made are 
both numerous and important. The attraction 
and the permanent character of this book lie in 
the clearness and truth of the clinical descriptions 
of diseases; the fertility of the author in thera- 
peutic resources and the fulness with which the 
details of treatment are described; the definite 
character of the teaching; and last, but not least, 
the evident candor which pervades it. — London 
Medical Times and Gazette, July 30, 1881. 



That the previous editions of the treatise of Dr. 
Thomas were thought worthy of translation into 
German, French, Italian and Spanish, is enough 
to give it the stamp of genuine merit. At home it 
has made its way into the library of every obstet- 
rician and gynaecologist as a safe guide to practice. 
No small number of additions have been made to 
the present edition to make it correspond to re- 
cent improvements in treatment. — Pacific Medical 
and Surgical Journal, Jan. 1881. 



EDIS, ARTHUR W., M. &., Land., F.K. C.P., M.M. C.S. ? 

Assist. Obstetric Physician to Middlesex Hospital, late Physician to British Lying-in Hospital. 
The Diseases of Women. Including their Pathology, Causation, Symptoms, 
Diagnosis and Treatment. A Manual for Students and Practitioners. In one handsome 
octavo volume of 576 pages, with 148 illustrations. Cloth, $3.00 ; leather, $4.00. 

It is a pleasure to read a book so thoroughly 
good as this one. The special qualities which are 
conspicuous are thoroughness in covering the 
whole ground, clearness of description and con- 
ciseness of statement. Another marked feature of 
the book is the attention paid to the details of 



many minor surgical operations and procedures, 
as, for instance, the use of tents, application of 
leeches, and use of hot water injections. These 



are among the more common methods of treat- 
ment, and yet very little is said about them in 
many of the textbooks. The book is one to be 
warmly recommended especially to students and 
general practitioners, who need a concise but com- 
plete rtsume of the whole subject. Specialists, too, 
will find many useful hints in its pages.— Boston 
Med. and Surg. Journ., March 2, 1882. 



BARNES, ROBERT, M. D., F. R. C. P., 

Obstetric Physician to St. Thomas' Hospital, London, etc. 

A Clinical Exposition of the Medical and Surgical Diseases of Women. 

In one handsome octavo volume, with numerous illustrations. New edition. Preparing. 



28 



Lea Brothers & Co.'s Publications — Dis. of Women, Midwfy. 



EMMET, THOMAS ADDIS, M. D., LL. I)., 

Surgeon to the Woman's Hospital, New York, etc. 

The Principles and Practice of Gynaecology; For the use of Students and 
Practitioners of Medicine. New (third) edition, thoroughly revised. In one large and very 
handsome octavo volume of 880 pages, with 150 illustrations. Cloth, $5; leather, $6; 
very handsome half Russia, raised bands, $6.50. 

We are in douot whether to congratulate the j only with honesty of purpose, but with aconscien- 
author more than the profession upon the appear- tious sense of responsibility, and a book that is at 
•nee of the third edition of this well-known work. I once a credit to its author and to American med- 
Embodying, as it does, the life-long experience of ical literature. We repeat that it is a book to b« 
one who has conspicuously distinguished himself studied, and one that is indispensable to every 
as a bold and successful operator, and who has practitioner giving any attention to gynaecology. — 
devoted so much attention to the specialty, we American Journal of the Medical Sciences, Af>Til,1886. 
feel sure the profession will not fail to appreciate I The time has passed when Emmet's Gynecology 
the privilege thus offered them of perusing the [ was to be regarded as a book for a single country 
views and practice of the author. His earnestness or for a single generation. It has always been his 
of purpose and conscientiousness are manifest. ! aim to popularize gynecology, to bring it within 
He gives not only his individual experience but ; easy reach of the general practitioner. The orig- 
endeavors to represent the actual state of gynw- inality of the ideas compels our admiration and 
cological science and art.— British Medical Jour- \ respect. We may well take an honest pride in 
nof.Mayli;, 1885. Dr. Emmet's work and feel that his book can 

No jot or tittle of the high praise bestowed upon I hold its own against the criticism of two eonti- 
the first edition is abated. It is still a book of nents. It represents all thai is most earnest and 
marked personality, one based upon large clinical i most thoughtful in American gynaecology.— Amer- 
experience, containing large and valuable ad- ' icnr. Journal of Obstetrics, May, 1885. 
ditions to our knowledge, evidently written not | 

DVNCAN, J. MATTHEWS, M.I)., LL. I>., F. It. S. E., etc. 

Clinical Lectures on the Diseases of Women ; Delivered in Saint Bar- 
tholomew's Hospital. In one handsome octavo volume of 175 pages. Cloth, $1.50. 

They are in every way worthy of their author ; ! rule, adequately handled in the text-books; others 
Indeed, we look upon them as among the most J of them, while bearing upon topics that are usually 
valuable of his contributions. They are all upon ; treated of at length in such works, yet bear such a 
matters of great interest to the general practitioner, stamp of individuality that they deserve to be 
Some of them deal with subjects that are not, as a ! widely read.— N. Y. Medical Journal, March, 1880. 

MAT, CHARLES H., M. D. 

Late House Surgeon to Mount Sinai Hospital, JYew York. 
A Manual of the Diseases of Women. Being a concise and systematic expo- 
sition of the theory and practice of gynaecology. In one 12mo. volume of 342 pages; 
Cloth, $1.75. 

tions, and the presentation only of accepted views, 
it constitutes a very satisfactory exposition of the 
leading principles of gynecology as they are un- 
derstood at the present time.— Cincinnati Medical 
News, Nov. 1885. 



Medical students will find this work adapted to 
their wauts. Also practitioners of medicine will 
find it exceedingly convenient to consult for the 
purpose of refreshing their minds upon the lead- 
ing points of a gynaecological subject. By syste- 
matic condensation, the omission of disputed ques- I 



HODGE, HVGHL., M. D., 

Emeritus Professor of Obstetrics, etc., in the University of Pennsylvania. 
On Diseases Peculiar to Women; Including Displacements of the Uterus. 
Second edition, revised and enlarged. In one beautifully printed octavo volume of 51 
pages, with original illustrations. Cloth, $4.50. 

By the Same Author. 
The Principles and Practice of Obstetrics. Illustrated with large litho- 
graphic plates containing 159 figures from original photographs, and with numerous wood- 
cuts. In one large quarto volume of 542 double-columned pages. Strongly bound in 
cloth, $14.00. Specimens of the plates and letter-press will be forwarded to any address, 
free by mail, on receipt of six cents in postage stamps. 

RAMSBOTHAM, FRANCIS H, M. D. 

The Principles and Practice of Obstetric Medicine and Surgery: 

In reference to the Process of Parturition. A new and enlarged edition, thoroughly revised 
by the Author. With additions by W. V. Keating, M. D., Professor of Obstetrics, etc., 
in the Jefferson Medical College of Philadelphia. In one large and handsome imperial 
octavo volume of 640 pages, with 64 full-page plates and 43 woodcuts in the text, contain- 
ing in all nearly 200 beautiful figures. Strongly bound in leather, with raised bands, $7. 

WINCKEL, F. 

A Complete Treatise on the Pathology and Treatment of Childbed, 

For Students and Practitioners. Translated, with the consent of the Author, from the 
second German edition, by J. R. Chadwick, M. D. Octavo 484 pages. Cloth, $4.00. 

WEST, CHARLESTM. D. 

Lectures on the Diseases of Women. Third American from the third Lon- 
don edition. In one octavo volume of 543 pages. Cloth, $3.75; leather, $4.75. 



ASHWELL'S PRACTICAL TREATISE ON THE 
DISEASES PECULIAR TO WOMEN. Third 
American from the third and revised London 
edition. In one 8vo. vol., pp. 520. Cloth, 83.50. 

CHURCHILL ON THE PUERPERAL FEVER 



AND OTHER DISEASES PECULIAR TO WO- 
MEN. In one 8vo. vol. of 464 pages. Cloth, 82.60. 
MEIGS ON THE NATURE, SIGNS AND TREAT- 
MENT OF CHILDBED FEVER. In one 8vo. 
volume of 346 pages. Cloth, 82.00. 



Lea Brothers & Co.'s Publications — Midwifery. 



29 



FARttJST, THEOPHILVS, M. D., LL. D., 

Prof, of Obstetrics and the Diseases of Women and Children in Jefferson Med. Coll., Phila. 

The Science and Art of Obstetrics. In one handsome 8vo. volume of 697 
pages, with 214 engravings and a colored plate. Cloth, $4.25 ; leather, $5.25. 



It is a ripe harvest that Dr. Parvin offers to his 
readers. There is no book that can be more safely 
recommended to the student or that can be turned 
to in moments of doubt with greater assurance of 
aid, as it is a liberal digest of safe counsel that has 
been patiently gathered. — The American Journal 
of the Medical Sciences, July, 1887. 

There is not in the language a treatise on the 
subject which so completely and intelligently 
gleans the whole field of obstetric literature, giv- 
ing the reader the winnowed wheat in concise and 
well-jointed phrase, in language of exceptional 
purity and strength. The arrangement of the 
matter of this work is unique and exceedingly 



favorable for an agreeable unfolding of the science 
and art of obstetrics. This new book is the easy 
superior of any single work among its predeces- 
sors for the student or practitioner seeking the 
best thought of the day in this department of 
medicine. — The American Practitioner and News, 
April 2, 1887. 

This treatise may be defined as exact, concise 
and scholarly. Parvin's distinguished position as 
a teacher, his scholarly attainments, and his 
honest endeavor to do his best by both the student 
and the physician, will secure for his treatise 
favorable recognition.— American Journal of Obstet- 
rics, May, 1887. 



BARNES, ROBERT, M. D., and FANCOURT, M. JD., 

Phys. to the General Lying-in Hosp., Lond. Obstetric Phys. to St. Thomas' Hasp., Lond. 

A System of Obstetric Medicine and Surgery, Theoretical and Clin- 
ical. For the Student and the Practitioner. The Section on Embryology contributed by 
Prof. Milnes Marshall. In one handsome octavo volume of 872 pages, with 231 illus- 
trations. Cloth, $5 ; leather, $6. 



This system will be eagerly sought for, not only 
on account of its intrinsic merit, but also because 
the reputation which the elder Barnes, in particu- 
lar, has secured, carries with it the conviction that 



any book emanating from him is necessarily sound 
in teaching and conservative in practice. It is in- 
deed eminently fitting that a man who has done so 
much towards systematizing the obstetric art, who 
for so many years has been widely known as a capa- 



ble teacher and trusted accoucheur, should embody 
within a single treatise the system which he has 
taught and in practice tested, and wh ich is the out- 
come of a lifetime of earnest labor, careful obser- 
vation and deep study. The result of this arrange- 
ment is the production ot a work which rises above 
criticism and which in no respect need yield th« 
palm to any obstetrical treatise hitherto published. 
—American Journal of Obstetrics, Feb. 1886. 



PL ATE AIR) W. S., M. !>., E. R. C. E., 

Professor of Obstetric Medicine in King's College, London, etc. 

A Treatise on the Science and Practice of Midwifery. New (fourth) 
American, from the fifth English edition. Edited, with additions, by Bobert P. Har- 
ms, M. D. In one handsome octavo volume of 654 pages, with 3 plates and 201 engrav- 
ings. Cloth, $4 ; leather, $5 ; half Eussia, $5.50. 

This still remains a favorite in America, not 
only because the author is recognized as a safe 
guide and eminently progressive man, but also as 
sparing no effort to make each successive edition 
a faithful mirror of the latest and best practice. 
A work so frequently noticed as the present 
requires no further review. We believe that this 
edition is simply the forerunner of many others, 
and that the demand will keep pace with the 



supply. — American Journal of Obstetrics, Nov. 1885. 
Since its first publication, only eight years ago, 
it has rapidly become the favorite text-book, to 
the practical exclusion of all others. A large 
measure of its popularity is due to the clear and 
easy style in which it is written. Few text-books 
for students have very much to boast of in this 
respect. — Medical Record. 



KIJVG, A. F. A., M. E., 

Professor of Obstetrics and Diseases of Women in the Medical Department of the Columbian Univer- 
sity, Washington, D. C., and in the University of Vermont, etc. 
A Manual of Obstetrics. New (third) edition. In one very handsome 12mo. 
volume of 376 pages, with 102 illustrations. Cloth, $2.25. 



This little manual, certainly the best of its kind, 
fully deserves the popularity which has made a 
third edition necessary. Clear, practical, concise, 
its teachings are so fully abreast with recent ad- 
vances in obstetric science that but few points 
can be criticised. — American Journal of Obstetrics, 
March, 1887. 

This volume deserves commendation. It is not 



bulky — it is concise. The chapters are divided with 
sub-headings, which aid materially in the finding 
of any particular subject, and the definitions are 
clear and explicit. It fulfils its purpose admirably, 
and we know of no better work to place in the stu- 
dent's hands. The illustrations are good. — Arch- 
ives of Gynecology, January, 1887. 



BARKER, FOUDYCE, A. M., M. D., LL. JD. Edin., 

Clinical Professor of Midwifery and the Diseases of Women in the Bellevue Hospital Medical College, 
New York, Honorary Fellow of the Obstetrical Societies of London and Edinburgh, etc., etc. 

Obstetrical and Clinical Essays. In one handsome 12mo. volume of about 
Preparing. 



BARJNES, FAN COURT, M. !>., 

Obstetric Physician to St. Thomas' Hospital, London. 

A Manual of Midwifery for Midwives and Medical Students. In one 

royal 12mo. volume of 197 pages, with 50 illustrations. Cloth, $1.25. 

BARRY, JOBJJS S., M. D., 

Obstetrician to the Philadelphia Hospital, Vice-President of the Obstet. Society of Philadelphia. 
Extra - Uterine Pregnancy: Its Clinical History, Diagnosis, Prognosis and 
Treatment. In one handsome octavo volume of 272 pages. Cloth, $2.50. 



TANNER ON PREGNANCY. Octavo, 490 pages, 4 colored plates, 16 cuts. Cloth, 84.25. 



30 



Lea Brothers & Co.'s Publications — Midwf'y., Dis. Cliildn. 



LEISHMAJN, WILLIAM, 31. JO., 

Regius Professor of Midwifery in the University of Glasgow, etc. 

A System of Midwifery, Including the Diseases of Pregnancy and the 
Puerperal State. Third American edition, revised by the Author, with additions by 
John S. Parry, M. D., Obstetrician to the Philadelphia Hospital, etc. In one large and 
very handsome octavo volume of 740 pages, with 205 illustrations. Cloth, $4.50; leather, 
$5.50 ; very handsome half Kussia, raised bands, $b\00. 

The author is broad In his teachings, and dis- must prove admirably adapted. Complete in all its 
cusses briefly the comparative anatomy of the pel- parts, essentially modern in its teachings, and with 
vis and the mobility of the pelvic articulations, demonstrations noted for clearness and precision, 



The second chapter is devoted especially 
the study of the pelvis, while in the thircf the 
female organs of generation are introduced. 
The structure and development of the ovum are 
admirably described. Then follow chapters upon 
the various subjects embraced in the study of mid- 
wifery. The descriptions throughout the "work are 
plain aud pleasing. It is sufficient to state that in 
this, the last edition of this well-known work, every 
recent advancement in this field has been brought 
forward. — Physician and Surgeon, Jan. 1880. 
To the American student the work before us 



it will gain in favor and be recognized as a work 
of standard merit. The work cannot fail to be 
popular and is cordially recommended.— N. O. 
Med. and Surg. Journ., March. 1880. 

It has been well and carefully written. The 
views of the author are broad and liberal, and in- 
dicate a well-balanced judgment and matured 
mind. We observe no spirit of dogmatism, but 
the earnest teaching of the thoughtful observer 
and lover of true science. Take the volume as a 
whole, and it has few equals. — Maryland Medical 
Journal, Feb. 1880. 



LANHIS, HENRY G., A. 31., 31. !>., 

Professor of Obstetric* and the Diseases of Women in Starling Medical College, Columbus, O. 

The Management of Labor, and of the Lying-in Period. In one 
handsome 12mo. volume of 334 pages, with 28 illustrations. Cloth, $1.75. 

The author has designed to place in the bands tempt any one who should happen to commence 
of the young practitioner a book in which he can the book' to read it through. The author pre- 
find necessary information in an instant. As far i supposes a theoretical knowledge of obstetrics, 
as we can see, nothing is omitted. The advice is ; and has consistently excluded from this little 
sound, and the prcceedures are safe and practical, work everything that is not of practical use in the 



Cmtralblatt fur Gynakologie, December 4,1886. 

This is a book we can heartily recommend. 
The author goes much more practically into the 

details of the management of labor than most | cal and Surgical Journal, Mar. 1886, 
text-books, and is so readable throughout as to 



lying-in room. We think that if it is as widely 
read as it deserves, it will do much to improve 
obstetric practice in general.— New Orleans Met 



S3IITH, J. LEWIS, 31. D., 

Clinical Professor of Diseases of Children in the Bellevue Hospital Medical College, N. 7, 

A Treatise on the Diseases of Infancy and Childhood. New (sixth) 
edition, thoroughly revised and rewritten. In one handsome octavo volume of 867 
paj:es, with 40 illustrations. Cloth, $4.50 ; leather, $5.50 ; half Kussia, $6.00. 

Rarely does a pleasanter task fall to the lot of stands alone amongst other works on its subject, 
the bioliographerthan toannounce the appearance of recommending treatment in accordance with 
of a new edition of a medical classic like Prof. J. the most recent therapeutical views. — British and 
Lewis Sniith's Treatise on the Diseases of Infancy ' Foreign Medico-Chirurgical Review, 
and Childhood. For years it has stood high in the \ It is a pleasure to the busy practitioner— inter- 
confidence of the profession, and with the addi- ested in the advancement of his profession— to 
tions and alterations now made it may be said to I meet, fresh from the hands of its author, a medi- 
be the best book in the language on the subject of cal classic such as Smith on Diseases of Children, 
which it treats. An examination of the text fully Those familiar with former editions of the work 
sustains the claims made in the preface, that "in ! will readily recognize the painstaking with which 

fireparingthe sixth edition the author has revised i this revision has been made. Many of the articles 
he text to such an extent that a considerable have been entirely rewritten. The whole work is 
pan of the book may be considered new." If the J enriched with a research and reasoning which 
young pi actitioner proposes to place in his library ] plainly show that the author has spared neither 
but one book on the diseases, of children, we | time nor labor in bringing it to its present ap- 
would unhesitatingly sav, let that book he the one proach towards perfection. The extended table of 
which is the subject" of this notice.— The American ! coutents ami the well-prepared index will enable 
Journal of the Medical Sciences, April, 1886. the busy practitioner to reach readily and quickly 

No better work on children's diseases could be j for reference the various subjects treated of in the 
placed in the hands of the student, containing, as . body of the work, and even those who are familiar 
it does, a very complete account of the symptoms ' with former editions will find the improvements 
and pathology of ihe diseases of early life, and j in the present richly worth the cost of the work. — 
possessing the further advantage, in which it Atlanta Medical and Surgical Journal, Deo. 1886. 



OWEN, EDMUND, 31. B., F. JR. C. S., 

Surgeon to tht Children's Hospital, Great Ormond St., London. 

Surgical Diseases of Children. In one 12mo. volume of 525 pages, with 4 

chromo-lithographic plates and 85 woodcuts. Cloth, $2. Bee Series of Clinical Manuals, 
page 4. 



One is immediately struck on reading this book 
with its agreeable style and the evidence it every- 
where presents of the practical familiarity of its 
author with his subject. The book may be 



honestly recommended to both students and 
practitioners. It is full of sound information, 
pleasantly given.— Annals of Surgery, May, 1886. 



WEST, CHARLES, 31. I)., 

Physician to the Hospital for Sick Children, London, etc. 

On Some Disorders of the Nervous System in Childhood. 
12mo. volume of 127 pages. Cloth, $1.00. 



In one 6mall 



WEST'S LECTURES OX THE DISEASES OF IN- 
FANCY AND CHILDHOOD. In one octavo vol. 
CONDI E'S PRACTICAL TREATISE ON THE 



DISEASES OF CHILDREN. Sixth edition, re- 
vised and augmented. In one octavo volume of 
779 pages. Cloth. $.5.25 ; leather, $6.25. J 



Lea Brothers & Co.'s Publications — Med. Juris., Miscel. 



31 



TIDY, CHARLES MEYMOTT, M. B., E. C. S., 

Professor of Chemistry and of Forensic Medicine and Public Health at the London Hospital, etc. 

Legal Medicine. Volume II. Legitimacy and Paternity, Pregnancy, Abor- 
tion, Rape, Indecent Exposure, Sodomy, Bestiality, Live Birth, Infanticide^ Asphyxia, 
Drowning, Hanging, Strangulation, Suffocation. Making a very handsome imperial oc- 
tavo volume of 529 pages. Cloth, $6.00 ; leather, $7.00. 

Volume I. Containing 664 imperial octavo pages, with two beautiful colored 
plates. Cloth, $6.00 ; leather, $7.00. 



The satisfaction expressed with the first portion 
of this work is in no wise lessened by a perusal of 
the second volume. We find it characterized by 
the same fulness of detail and clearness of ex- 
pression which we had occasion so highly to com- 
mend in our former notice, and which render it so 
Taluable to the medical jurist. The copious 



tables of cases appended to each division of the 
subject must have cost the author a prodigious 
amount of labor and research, but they constitute 
one of the most valuable features of the book, 
especially for reference in medico-legal trials. — 
A merican Journal of the Medical Sciences, April, 1884. 



TAYLOR, ALFRED S., M. D., 

Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital, London. 
A Manual of Medical Jurisprudence. Eighth American from the tenth Lon- 
don edition, thoroughly revised and rewritten. Edited by John J. Reese, M. D., Professor 
of Medical Jurisprudence and Toxicology in the University of Pennsylvania. In one 
large octavo volume of 937 pages, with 70 illustrations. Cloth, $5.00 ; leather, $6.00; half 
Russia, raised bands, $6.50. 



^The American editions of this standard manual 
have for a long time laid claim to the attention of 
the profession in this country; and the eighth 
comes before us as embodying the latest thoughts 
and emendations of Dr. Taylor upon the subject 
to which he devoted his life with an assiduity and 
success which made him facile princeps among 
English writers on medical jurisprudence. Both 
the author and the book have made a mark too 
deep to be affected by criticism, whether it be 
censure or praise. In this case, however, we should 



only have to seek for laudatory terms. — American 
Journal of the Medical Sciences, Jan. 1881. 

This celebrated work has been the standard au- 
thority in its department for thirty-seven years, 
both in England and America, in both the profes- 
sions which it concerns, and it is improbable that 
it will be superseded in many years. The work is 
simply indispensable to every physician, and nearly 
so to every liberally-educated lawyer, and wo 
heartily commend the present edition to both pro- 
. — Albany Law Journal, March 26, 1881. 



By the Same Author. 
The Principles and Practice of Medical Jurisprudence. Third edition. 
In two handsome octavo volumes, containing 1416 pages, with 188 illustrations. Cloth, $10 ; 
leather, $12. 



For years Dr. Taylor was the highest authority 
in England upon the subject to which he gave 
especial attention. His experience was vast, his 
judgment excellent, and his skill beyond cavil. It 
is therefore well that the work of one who, as Dr. 
Stevenson says, had an "enormous grasp of all 



matters connected with the subject," should bo 
brought up to the present day and continued in 
its authoritative position. To accomplish this re- 
sult Dr. Stevenson has subjected it to most careful 
editing, bringing it well up to the times. — Ameri- 
can Journal of the Medical Sciences, Jan. 1884. 



By the Same Author. 

Poisons in Relation to Medical Jurisprudence and Medicine. Third 
American, from the third and revised English edition. In one large octavo volume of 788 
pages. Cloth, $5.50 ; leather, $6.50. 

PEPPER, AUGUSTUS J., M. 8., M. B., F. R. C. 8., 

Examiner in Forensic Medicine at the University of London. 
Forensic Medicine. In one pocket-size 12mo. volume. Preparing. See Students? 
Series of Manuals, page 4. 

LEA, HENRY C. ~ 

Superstition and Force : Essays on The Wager of Law, The Wager of 
Battle, The Ordeal and Torture. Third revised and enlarged edition. In one 

handsome royal 12mo. volume of 552 pages. Cloth, $2.50. 



This valuable work is in reality a history of civ- 
ilization as interpreted by the progress of jurispru- 
dence. . . In " Superstition and Force " we have a 
philosophic survey of the long period intervening 
between primitive barbarity and civilized enlight- 
enment. There is not a chapter in the work that 



should not be most carefully studied ; and however 
well versed the reader may be in the science of 
jurisprudence, he will find much in Mr. Lea's vol- 
ume of which he was previously ignorant. The 
book is a valuable addition to the literature of so- 
cial science.— Westminster Review, Jan. 1880. 



By the Same Author. 
Studies in Church History. The Rise of the Temporal Power— Ben- 
efit of Clergy — Excommunication. New edition. In one very handsome royal 
octavo volume of 605 pages. Cloth, $2.50. 

The author is pre-eminently a scholar. He takes primitive church traced with so much clearness, 
up every topic allied with the leading theme, and and with so definite a perception of complex or 
traces it out to the minutest detail with a wealth conflicting sources. The fifty pages on the growth 
of knowledge and impartiality of treatment that of the papacy, for instance, are admirable for con- 
compel admiration. The amount of information ciseness and freedom from prejudice. — Boston 
compressed into the book is extraordinary. In no Traveller, May 3, 1883. 
other single volume is the development of the 



An American System of Dentistry 
•Ashhurst's S ur ge r y .... 

Ashwell on Diseases of Women 

A tt field's Chemistry .... 

Ball on the Rectum and Anus 

Barker's Obstetrical and Clinical Essays, 

Barlow's Practice of Medicine 

Barnes' Midwifery .... 

•Barnes on J iiseases of Women 

Barnes' System of Obstetric Medicine 

Bartholow on Electricity 

Bartholow's New Remedies and their Uses 

Basham on Renal Diseases . 

Bell's Comparative Physiology and Anatomy 

Bellamy's Operative Surgery 

Bellamy's Surgical Anatomy 

Blandford on insanity 

Bloxam's Chemistry .... 

•Bristowe's Practice of Medicine . 

Broadbent on the Pulse 

Browne on the Ophthalmoscope 

Browne on the Throat, Nose and Ear 

Bruce's Materia Medica and Therapeutics 

Brunton's Materia Medica and Therapeutics 



Butlin on the Tongue .... 

Carpenter on the Use and Abuse of Alcohol 

•Carpenter's Human Physiology 

Carter & Frost's ( iphthalmic Surgery 

Century of American Medicine 

Chambers on Diet and Regimen 

Chapman's Human Physiology 

Charles' Physiological and Pathological Ctaem 

Churchill on Puerperal Fever 

Clarke and Lock wood's Dissectors' Manual 

Classen's Quantitative Analysis 

Cleland's Dissector .... 

Clouston on Insanity .... 

Clowes' Practical Chemistry 

Coats' Pathology .... 

Cohen on the Throat .... 

Coleman's Dental Surgery 

Condie on Diseases of children 

Cornil on Syphilis .... 

•Cornll and Rauvier's Pathological Histology 

Cullerier's Atlas of Venereal Diseases 

Curnow's Medical Anatomy 

Dalton on the Circulation 

•Dalton's Human Physiology 

Davis' Clinical Lectures 

Draper's Medical Physics 

Druitt's Modern Surgery 

Duncan on Diseases of Women 

•Du nglison's Medical Dictionary . 

Ede.s' Materia Medica and Therapeutics 

Edis on Diseases of Women . 

Ellis' Demonstrations of Anatomy 

Emmet's gynaecology 

•Erichsen s System of Surgery 

Esmarch's Early Aid in Injuries and Accid'ts 

Farquharson's Therapeutics and Mat. Med. 

Fenwick's Medical Diagnosis 

Finlayson's Clinical Diagnosis 

Flint on Auscultation and Percussion 

Flint on Phthisis .... 

Flint on Physical Exploration of the Lungs 

Flint on Respiratory Organs 

Flint on the Heart .... 

Flint's Essays ... 

♦Flint's Tactice of Medicine 

Folsom's Laws of U. S. on Custody of Insane 

Foster's Physiology .... 

•Fothergill's Handbook of Treatment . 

Fownes' Elementary Chemistry 

Fox on Diseases of the Skin . 

Frankland and Japp's Inorganic Chemistry 

Fuller on the Lungs and Air Passages . 

Galloway's Analysis 

Gibnev'sOrtliopa-dic Surgery 

Gould's Surgical Diagnosis . 

♦Gray's Anatomy ..... 

Greene's Medical Chemistry . 

Green's Pathology and Morbid Anatomy 

Griffith's Universal Formulary 

Gross on Foreign Bodies in Air-Passages 

Gross on Impotence and Sterility . 

Gross on Urinary Organs 

•Gross' System of Surgery 

Habershon on the Abdomen 

♦Hamilton on Fractures and Dislocations 

Hamilton on Nervous Diseases 

Hartshorne's Anatomy and Physiology . 

Hartshorne's Conspectus of the Med. Sciences 

Hartshorne's Kssentials of Medicine 

Hartshorne's Household Medicine 
Hermann's Experimental Pharmacology 

Hill on syphilis 

Hiiiier's Handbook of Skin Diseases 
Hoblyn's Medical Dictionary 
Hodge on Women .... 

Hodge's Obstetrics .... 
Hoffmann and Power's Chemical Analysis 
Holden's Landmarks .... 
Holland's Medical Notes and Reflections 



4,90 
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19 



14 

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Is 



21 

25 

23 

4,21 



14 

17 
8 
10 
28 

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10 
6 
19 
10 
13 
18 
24 



♦Holmes' System of Surgery 
Horner's Anatomy and Histology . 
Hudson on Fever 

Hutchinson on Syphilis 
Hyde on the Diseases of the 8kln . 
Jones (C. Handfleldi on Nervous Disorders 
Juler's Ophthalmic Science and Practice 
Kaposi on Skin Diseases 
King's Manual of Obstetrics . 
Klein's Histology .... 

Landis on Labor .... 

La Roche on Pneumonia, Malaria, etc. . 
La Roche on Yellow Fever . 
Laurence and Moon's Ophthalmic Surgery 
Lawson on the Eye, Orbit and Eyelid 
Lea's Studies in Church History 
Lea's superstition and Force 
Lee on Syphilis 

Lehmanh s Chemical Physiology . 
♦Leishman's Midwifery 
Lucas on Diseases of the Urethra . 
Ludlow's Manual of Examinations 
Lyons on Fever ..... 
Maisch's Organic Materia Medica . 
Marsh on the Joints 
May on Diseases of Women . 
Medical News 

Medical News Visiting List . 
Medical News Physicians' Ledger . 
Meigs on Childbed Fever 
Miller's Practice of Surgery . 
Miller's Principles of surgery 
Mitchell's Nervous Diseases of Women . 
Morris on Diseases of the Kidney . 
Neill and Smith's < 'ompendlum of Med. Sci. 
Nettleship on Diseases of the Eye . 
Norris and Oliver on the Eye 
Owen on Diseases of Children 
•Parrish's Practical Pharmacy 
Parry on Extra Uterine Pregnancy 
Parvin's Midwifery 
Paw on Digestion and Its Disorders 
Pepper's System of Medicine 
Pepper's Forensic Medicine . 
Pepper's surgical Pathology 
Pick on Fractures and Dislocations 
Pirrie's System of Surgery . 
Playfair on Nerve Prostration and Hysteria 
•Playfair'a Midwifery . • 
Politzer on the Ear and its Diseases 
Power's Human Physiology . 
Dimly on Lright's i Msease and Allied Afiections 
Ralfe's Clinical Chemistry 
Ramsbothani on Parturition 
Remsen's Theoretical Chemistry . 
♦Reynolds' System of Medicine 
Richardson's Preventive Medicine 
Roberts on Urinary Diseases 
Roberts' Compend" of Anatomy 
Roberts' Principles and Practice of Surgery 
Robertson's Physiological Physics 
Ross on Nervous Diseases 
Savage on Insanity, including Hysteria . 
Schafer's Essentials of Histology, 
Schreiber on Massage . 

Seller on the Throat, Nose and Naso-Pharynx 
Series of Clinical Manuals 
Simon's Manual of Chemistry 
Skey's Operative Surgery 
Slade on Diphtheria .... 
Smith (Edward i on Consumption . 
♦Smith ( J. Lewis) on Children 
Smith's Operative Surgery . 
Stllle on Cholera .... 

♦Stille & Maisch's National Dispensatory 
♦Stille's Therapeutics and Materia Medica 
Stimson on Fractures and Dislocations, 
Stimson's Operative Surgery 
Stokes on Fever ..... 
Students' Series of Manuals . 
Sturges' Clinical Medicine 
Tanner on Signs and Diseases of Pregnancy 
Tanner's Manual of Clinical Medicine . 
Taylor's Atlas of Venereal and Skin Diseases 
Taylor on Poisons .... 

•Taylor's Medica] Jurisprudence . 
Taylor's Prin. and Prac. of Med. Jurisprudence 
♦Thomas on Diseases of Women . 
Thompson on Stricture 
Thompson on Urinary Organs 
Tidy's Legal Medicine .... 
j Todd on Acute Diseases 
Treves' Manual of Surgery . 
Treves' Surgical Applied Anatomy 
Treves on Intestinal Obstruction . 
Tiike on the Influence of Mind on the Body 
Visiting List, The Medical News . 
Wo Ishe on the Heart .... 
Watson's Practice of Physic . 
♦Wells on the Eye .... 
West on Diseases of Childhood 
Weston Diseases of Women 
West on Nervous Disorders in Childhood 
Williams on Consumption . 
Wilson's Handbook of Cutaneous Medicine 
Wilson's Human Anatomy . 
Winckel on Pathol, and Treatment of Childbed 
Wfihler's Organic Chemistry 
Woodhead's Practical Pathology . 
Year-Books of Treatment for 1886 and 1887 



4,25 

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29 
4,13 
30 
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14 
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8 
30 

4,24 
8 
14 
11 

4,22 
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12 
12 
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17 
29 
18 
26 
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31 
81 
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24 
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31 
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Books marked * are also bound in half Russia. 



LEA BROTHERS & CO., Philadelphia. 



LIBRARY OF CONGRESS 



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